Age of Blood in Children in Pediatric Intensive Care Units
Phase: PHASE3
Conditions: Anemia
Sponsor: Washington University School of Medicine

 
 
 
 
 
 
 
 
Principal Investigators:  
Dr. Philip C. Spinella, Washington University School of Medicine, St-Louis 
 
 
 
 
 
Dr. Marisa Tucci, Ste-Justine Hospital, Montreal 
 
Co-Principal Investigators:  
Dr. Jacques Lacroix, St-Justine Hospital, Montreal 
 
Co-investigators and Steering Committee Members:  
 
 
 
 
 
Dr. Robert Berg, Children's Hospital of Philadelphia 
 
 
 
 
Dr. Jaime Caro, McGill University, Montreal 
 
 
 
 
Dr. Allan Doctor, Washington University School of Medicine, St-Louis 
 
 
 
 
Dr. Dean Fergusson, Ottawa Hospital Research Institute 
 
 
 
 
Dr. Paul Hébert, Montreal University Health Center 
 
 
 
 
Dr. Cassandra Josephson, Children's Healthcare of Atlanta 
 
 
 
 
Dr. Kusum Menon, Children’s Hospital of Eastern Ontario 
 
 
 
 
Dr. Kenneth Schechtman, Washington University School of Medicine, St-Louis 
 
 
 
 
Dr. Christopher Silliman, University of Colorado Denver, Aurora 
 
 
 
 
Dr. Marie Steiner, University of Minnesota, Minneapolis 
 
 
 
 
Dr. Alan Tinmouth, Ottawa General Hospital 
 
 
 
 
Dr. Alexis Turgeon, Hôpital de l'Enfant-Jésus, Quebec 
 
Medical Monitor: 
Dr. Scot Bateman, University of Massachusetts Medical Center 
 
Coordinating centers:  International Coordinating Center, Research Centre, Sainte-Justine Hospital,  
 
 
Université de Montréal 
 
 
US Coordinating Center, Washington University School of Medicine, St. Louis, MO  
 
Study managers:  
Lucy Clayton, BSc, MSc  
 
 
 
 
Tina Bockelmann, MSW, CCRP 
 
Protocol Date:  
13- Mar-2017 
 
 
 
 
  
 
 
 
 
 
 
Financial support:  
National Heart, Lung, and Blood Institute (NHLBI) 
 
 
 
 
Canadian Institutes of Health Research (CIHR) 
 
 
 
 
Ministère de la Santé et des Services Sociaux (MSSS) 
 
 

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PROTOCOL SIGNATURES 
 
This study is intended to be conducted in compliance with the protocol, Good Clinical Practice and the 
applicable regulatory requirements. 
 
 
 
 
 
 
Dr. Philip Spinella 
 
 
 
 
 
 
 
 
 
 
 
March 13, 2017 
 
 
 
 
 
 
 
Signature 
 
 
 
Date 
Lead Coordinating Principal Investigator  
Washington University School Of Medicine 
660 South Euclid, Campus box 8116 
Saint Louis, MO, 63110 
 
 
 
 
 
Dr. Marisa Tucci 
 
 
 
 
 
 
 
 
 
 
 
March 13, 2017 
 
 
 
 
 
 
 
Signature 
 
 
 
Date 
Lead Coordinating Principal Investigator 
Sainte-Justine Hospital 
University of Montreal 
3175 Côte Sainte-Catherine 
Montreal, Quebec, Canada H3T 1C5 
 
 
 
 
 
 
 
 
Printed Name:  
 
 
 
Signature 
 
 
 
Date 
Coordinating Investigator 
 
 
 
 
 
 
 
 
 

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TABLE of CONTENT 
1. 
GENERAL INFORMATION .............................................................................................................................. 1 
2. 
BACKGROUND INFORMATION ...................................................................................................................... 1 
2.1. 
CHANGES IN RBCS DURING THE STORAGE PROCESS .................................................................................................... 1 
2.2. 
PHYSIOLOGICAL EFFECTS ASSOCIATED WITH RBC STORAGE .......................................................................................... 1 
2.3. 
PEDIATRIC STUDIES EXAMINING RBC STORAGE AGE AND OUTCOMES ............................................................................. 2 
3. 
TRIAL HYPOTHESIS AND PURPOSE ................................................................................................................ 2 
4. 
TRIAL DESIGN ............................................................................................................................................... 2 
4.1. 
PRIMARY AND SECONDARY OUTCOME MEASURES ...................................................................................................... 3 
4.1.1. 
Primary outcome .................................................................................................................................... 3 
4.1.2. 
Secondary outcomes .............................................................................................................................. 3 
4.2. 
TYPE OF TRIAL .................................................................................................................................................... 3 
4.3. 
TARGET POPULATION ........................................................................................................................................... 3 
4.4. 
MEASURES TO AVOID BIAS ................................................................................................................................... 3 
4.5. 
RANDOMIZATION ................................................................................................................................................ 4 
4.5.1. 
Concealment of Randomization ............................................................................................................. 4 
4.5.2. 
Stratification ........................................................................................................................................... 4 
4.5.3. 
Blinding ................................................................................................................................................... 4 
4.5.4. 
Trial Treatment and Co-Interventions .................................................................................................... 5 
4.6. 
STUDY PARTICIPANT DURATION ............................................................................................................................. 5 
4.7. 
SELECTION AND WITHDRAWAL OF PATIENTS ............................................................................................................. 5 
4.7.1. 
Screening and consent procedures ......................................................................................................... 5 
4.7.2. 
Eligibility criteria ..................................................................................................................................... 7 
4.7.3. 
Inclusion criteria ..................................................................................................................................... 7 
4.7.4. 
Exclusion criteria .................................................................................................................................... 7 
4.8. 
DURATION OF TREATMENT PERIOD AND FOLLOW UP ................................................................................................... 8 
4.9. 
STOPPING RULES OR DISCONTINUATION CRITERIA ..................................................................................................... 8 
4.10. 
PATIENT WITHDRAWAL ...................................................................................................................................... 8 
4.11. 
SAMPLE SIZE .................................................................................................................................................... 9 
4.12. 
RECRUITMENT RATE .......................................................................................................................................... 9 
4.13. 
COMPLIANCE ................................................................................................................................................... 9 
4.13.1. 
Measures to ensure compliance ........................................................................................................... 9 
4.13.2. 
Compliance with the intervention ...................................................................................................... 10 
4.14. 
RATE OF LOSS TO FOLLOW-UP ............................................................................................................................ 10 
4.15. 
TYPE AND FREQUENCY OF ANALYSES .................................................................................................................... 11 
4.15.1. 
Philosophy of analysis ........................................................................................................................ 11 
4.15.2. 
Baseline characteristics ...................................................................................................................... 11 
4.15.3. 
Intervention and co-interventions ...................................................................................................... 11 
4.15.4. 
Analysis of primary outcome .............................................................................................................. 11 
4.15.5. 
Analyses of secondary outcome measures and subgroup analyses ................................................... 12 
4.15.6. 
Other statistical analyses and specific considerations ....................................................................... 13 
4.15.7. 
Data collected .................................................................................................................................... 14 
4.15.8. 
Data Safety Monitoring Board and Interim Analyses ......................................................................... 14 
4.16. 
ADVERSE EVENTS/ SERIOUS ADVERSE EVENTS ...................................................................................................... 16 
5. 
SECURITY .................................................................................................................................................... 19 
5.1. 
COMPLIANCE TO PRIVACY-SECURITY REGULATIONS .................................................................................................. 19 
5.2. 
ESTABLISHMENT OF CODING ............................................................................................................................... 19 
5.3. 
STUDY MONITORING AND STUDY ORGANIZATION ..................................................................................................... 19 

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STUDY MONITORING ......................................................................................................................................... 20 
5.5. 
STUDY ORGANIZATION AND COMMITTEE RESPONSIBILITIES ....................................................................................... 20 
5.6. 
STUDY ORGANIZATION AND COMMITTEE RESPONSIBILITIES ARE DESCRIBED IN THE MOP. ................................................ 20 
6. 
APPENDIX 1: DATA COLLECTION TIMELINE .................................................................................................. 21 
7. 
APPENDIX 2: PARTICIPATING INSTITUTIONS AND PRINCIPAL INVESTIGATORS ............................................. 22 
 
PART A: US SITES ................................................................................................................................................... 22 
7.1. .......................................................................................................................................................................... 22 
 
PART B: CANADIAN SITES ......................................................................................................................................... 29 
7.2. .......................................................................................................................................................................... 29 
7.3 
PART C: SITES IN FRANCE .................................................................................................................................... 30 
8. 
APPENDIX 3: DEFINITIONS OF AE’S/SAES .................................................................................................... 32 
9. 
APPENDIX 4: INTENT TO TREAT ANALYSIS ................................................................................................... 37 
10. 
PROTOCOL REFERENCES: .......................................................................................................................... 40 

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1. General Information 
The ABC PICU Trial is a randomized clinical trial (RCT) that will compare the clinical 
consequences of red blood cell (RBC) storage duration in 1538 critically ill children. Laboratory 
and observational evidence points to serious concerns about the lack of safety and effectiveness 
of older RBCs, especially in more vulnerable populations. Physicians and institutions have been 
systematically transfusing fresh RBCs to some pediatric patients primarily because of beliefs that 
short storage cells improve outcomes.  Conversely, the standard practice of blood banks is to 
deliver the oldest RBC unit in order to decrease blood wastage. To provide much needed high 
quality evidence to answer the question “do RBCs of reduced storage duration improve 
outcomes”, ABC PICU will conduct a RCT comparing development of New or Progressive 
Multiple Organ Dysfunction Syndrome (NPMODS) in critically ill children transfused with 
either RBCs stored ≤ 7 days or standard issue RBCs (expected mean RBC storage duration of 
17-21 days).  
2. Background Information 
2.1. Changes in RBCs during the storage process 
Blood procurement agencies determine the upper 
limit of RBC shelf life based upon a mean 
hemolysis of less than 1% (0.8% in Europe) and 
having > 75% of transfused circulating RBCs still 
alive in healthy volunteers 24 hours after 
transfusion1, 2. These regulations do not consider 
the numerous biochemical, structural, 
inflammatory, and physiologic changes that occur 
in stored RBCs in proportion to storage duration, 
sometimes referred to collectively as the  ‘‘RBC 
storage lesion”, which are indisputable, have been 
extensively described and may be deleterious 1-10. 
Biologic pathways and potential causes of the RBC storage lesions are displayed in the adjacent 
figure 111.  
2.2. Physiological effects associated with RBC storage 
Plausible mechanisms linking prolonged RBC storage to adverse effects in critically ill patients 
are shown in the figure above and include decreased microvascular perfusion, abnormal 
rheologic properties, increased recipient inflammation12,13 , increased production of oxidative 
injury mediators, hypercoagulability11, 14, decreased tissue oxygenation, and decreased tissue 
perfusion and oxygen consumption12, 15-25.  Many of these could have substantial impact in the 
critically ill. One very important physiologic impact relates to changes in microcirculatory flow, 
tissue oxygen delivery and utilization. RBCs play a role in oxygen-dependent vasoregulation26, 
27.   RBC storage affects intra-erythrocyte hemoglobin in banked RBCs which can impair RBC 
vasodilatory capacity in the microvasculature, which in turn can compromise regional oxygen 
delivery27-30. Impaired microcirculation can also result from increased generation of thrombin 
and procoagulant phospholipids which are increased in leukoreduced RBC units with prolonged 
storage time18-20. The combination of significantly impaired microcirculatory dysfunction and 
decreased RBC deformability may dramatically affect tissue oxygen delivery in patients with 
sepsis and septic shock. Another important physiologic impact of transfusion in the critically ill 
is its potential immunomodulatory effect39,50-54.  Indeed, prestorage leukoreduced RBC s with 

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increased storage times have been associated with immune effects that can be pro- and anti-
inflammatory31-36.  
Immunosuppressive effects of RBC transfusions have been documented by an increase in live 
births in women with a history of spontaneous abortions and increased post-operative infection 
risks12, 37, 38 as well as in reports describing transfusion-related immune modulation31, 33, 35, 39. 
Conversely, pro-inflammatory effects have also been attributed to bioactive lipids which 
accumulate with RBC storage and increase risk of acute lung injury12, 22, 40, 41.  
2.3. Pediatric studies examining RBC storage age and outcomes 
RBC transfusions are a frequent event in critically ill children. In Bateman et al, almost 50% of 
critically ill children in PICU for more than 2 days received at least 1 RBC transfusion42. There 
are few clinical studies that adequately explore the clinical consequences of prolonged RBC 
storage – and there have been no RCTs performed in children Most of the published data on the 
effect of RBC storage time in children has emanated from our group in two manuscripts that 
report an independent association between transfusion of RBC unit(s) with > 14 days of storage 
and increased risk of MODS43, 44. Karam et al43 published a secondary analysis of a prospective 
descriptive transfusion study conducted in 29 North American PICUs that included 296 
transfused children with a PICU length of stay > 48 hours. An independent association was 
measured between transfusion of ≥ 1 units of RBCs stored > 14 days and the primary outcome 
NPMODS, with an odds ratio of 1.87 (95% confidence interval, 1.06-3.31, p=0.03); an adjusted 
increase in PICU length of stay (+3.7 days, p<0.001) was also observed. Another study from our 
group, an analytic cohort analysis involving 455 transfused children enrolled in the (Transfusion 
Requirements in Pediatric Intensive Care Units (TRIPICU) RCT45, showed that transfusion of 
RBCs stored > 14 days was independently associated with increased NPMODS after adjusting 
for multiple variables at randomization. When all transfused patients were analyzed, the adjusted 
odds ratio for NPMODS was 2.3 (95% confidence interval, 1.24-4.28, p<0.05). No cause and 
effect relation could be established between RBC storage time and development of NPMODS in 
either study due to uncontrolled confounding by indication. An association between increased 
RBC age and mortality was not measured because mortality was too low (< 5%) in both 
cohorts43, 44.  
3. Trial Hypothesis and Purpose 
We hypothesize that transfusion of RBC units stored for ≤ 7 days to critically ill children will 
reduce the number of patients developing NPMODS by at least 6% (33% relative risk reduction), 
from 18% in children receiving standard issue RBCs to 12% in the short storage group.   
We have adopted a pragmatic approach to all design elements and have engaged a wide variety 
of pediatric hospitals in Canada and the US, with the potential to add sites from additional 
countries. There are minimum restrictions in patient eligibility, no controls on clinical practice 
and have chosen clinically important outcomes. The purpose of the ABC PICU Trial is to 
determine if the transfusion of RBCs ≤ 7 days will improve outcomes compared to the 
transfusion of standard issue RBCs. Results of the ABC PICU Trial will be generalizable since it 
is comparing an intervention with standard care. 
 
 
4. Trial Design 

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4.1. Primary and secondary outcome measures 
4.1.1. Primary outcome  
The primary outcome measure of this RCT is NPMODS defined as the proportion of patients 
who die during the 28 calendar days after randomization or who develop NPMODS.  For patients 
with no organ dysfunction at randomization, New MODS is the development of ≥ 2 concurrent 
organ dysfunctions during the 28 calendar days after randomization. For patients with 1 organ 
dysfunction at randomization, New MODS is the development of at least 1 other concurrent 
organ dysfunction after randomization. Patients with MODS (i.e. concurrent dysfunction of ≥ 2 
organ systems) at randomization can develop Progressive MODS defined as development of at 
least 1 additional concurrent organ dysfunction at during the 28 calendar days after 
randomization. All deaths will be considered Progressive MODS. NPMODS will be monitored 
up to 28 calendar days or PICU discharge because it is almost never observed beyond this time 
in children46.   
4.1.2. Secondary outcomes  
Clinically important secondary outcomes will include 28-day, and 90-day all-cause mortality. 
Nosocomial infections will be recorded, including nosocomial pneumonia and blood stream 
infection. Other secondary outcomes include PELOD2 score, severe sepsis, septic shock, acute 
respiratory distress syndrome (ARDS), mechanical ventilation, ICU free days and transfusion 
associated delirium using the Cornell Assessment for Pediatric Delirium (CAPD) with the 
exception of Canadian participating centers. We are not requesting to add this secondary 
outcome at Canadian sites due to the reduced reimbursement per patient in Canada. Site 
coordinators are already providing more effort than they are being reimbursed, therefore it is not 
feasible to add an additional outcome measure at these sites.  
 
 
4.2. Type of Trial 
The ABC PICU Trial is a multicenter international, pragmatic, double-blind, superiority, two-
arm RCT, in 1538 critically ill children, comparing the risk of NPMODS between patients 
transfused RBCs of decreased storage age (length of storage ≤ 7 days) and those transfused 
standard issue RBCs (stored 2-42 days with a documented average length of storage of about 17-
21 days). 
4.3. Target Population 
Based upon previously published data, for critically ill children who are expected to be in a ICU 
for > 24-48 hours and transfused, we expect the incidence rate of NPMODS to be 18% in the 
control and 12% in the experminental group.     
4.4. Measures to Avoid Bias 
Patients will be randomized to receive either standard issue RBCs or RBCs stored for ≤ 7 days. 
This intervention will be maintained in effect until 3 possible events, whichever occurs first: 1) 
28 calendar days elapse post-randomization; 2) hospital discharge; or 3) death.  
 
All RBC units will be prepared in accordance to existing local and national standards and 
collection and expiration date will be recorded by blood bank personnel not involved in the ABC 
PICU Trial as site investigators. While the decision to transfuse RBCs will not be protocolized, a 
summary of the current literature with guidance on transfusion thresholds is provided in the 
MOP.  All management decisions will be at the discretion of the clinical team. Whenever 

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possible, during the first 28 calendar days after randomization, only RBCs with shorter storage 
times will be given to patients allocated to the “short storage” arm; we recognize that this might 
be impossible in specific situations. Because the number of patients per site in the “short storage” 
arm of the trial will be small (1-3 patients per month), this trial will not affect the age of RBC 
units available to patients allocated to the usual care arm; this will be monitored during the trial 
by the Data and Safety Monitoring Board (DSMB) from data collected on total inventory RBC 
age at selected sites. 
4.5. Randomization  
The randomization process will consist of a computer-generated random listing of treatment 
allocation using a pre-established algorithm. The blood bank will contact the web randomization 
system for any eligible patient meeting inclusion and exclusion criteria. Time zero will be the 
time a patient is randomized to one arm of the study within the web randomization system (a 
date and time will be provided for each patient). Allocation will be in a 1:1 ratio. Randomization 
will be stratified by center and age.  The central randomization system will be a web-based 
automated system that will require confirmation of patient age and will have a backup in the 
form of an on-call statistician or designate at the Data Management Center (DMC) or Data 
Coordinating Center (DCC). Only the study statistician and DMC/DCC designate will have 
knowledge of randomization codes. Once a patient is randomized, an automated notification will 
be sent back by email to the blood bank.  
4.5.1. Concealment of Randomization  
Research personnel, ICU staff and other caregivers will not have access to the randomization 
schedule, nor to the allocation of participating patients. In order to conceal future allocation, 3 
sizes of blocks permutation (2, 4 and 6 patients/block) will be randomly used.   
4.5.2. Stratification  
Patients will be stratified at randomization according to center and age (≤ 28 days (as assessed by 
28 days after the day of birth), 29 to 365 days, and ≥ 1 year).  
Stratification by site and age will be employed since the possibility for unbalanced treatment 
allocation is possible given the diversity in case mix within each of the participating ICUs.  
The stratification tree will consist of 6 branches per center; two treatment strategies (“short 
storage” or “standard delivery” RBC units) and three age groups. 
 
Blocking will also be employed. Each stratification tree will contain multiple fixed blocks of 2, 4 
or 6 patients per block. An equal number of patients will be assigned to one of two treatments 
within each block, with the order of blocks (2, 4 or 6 patients per block) and the order of 
treatment assignment within blocks selected at random according to the computer-generated 
randomization scheme. This approach ensures good randomization concealment. 
4.5.3. Blinding 
Blinding will be used in the allocation process (concealment of randomization). Physicians, 
nurses, other caregivers and research staff will not be given any information regarding individual 
entries from the computer generated random list. To blind clinicians and research personnel from 
the treatment group patients were allocated to, opaque stickers will be put on expiration dates on 
the labels affixed to bags of RBC units; this will be done in the blood bank before any RBC unit 
is delivered to a patient participating in the ABC PICU Trial. The procedure for blinding 
expiration dates is in the MOP. Other important patient identifiers and blood grouping will not be 
masked from the clinical team. Accidental un-blinding of the expiration date of the unit of RBCs 

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will be documented and reported via the protocol deviation process.  The data of study patients 
with accidental un-blinding will be included in the intent to treat analysis. The incidence of 
accidental un-blinding will be reported within the trial manuscript.  
The use of a removable non-defacing label is necessary in case the unit that is sent to the study 
patient is not used and returned to the blood bank for use in another non-study patient. For local 
paperwork which accompanies the RBC unit, sites may use any method they see fit to conceal 
the dates on these locally generated documents. Only ABC PICU study approved opaque stickers 
may be used on RBC units.  
 
The diagnosis of NPMODS and the determination of the PELOD score will be done by research 
assistants who will be kept unaware of treatment allocation. All statistical analyses done at the 
end of the trial will be done without knowing treatment allocations. Dummy codes will be used 
to designate treatment allocation.  
4.5.4. Trial Treatment and Co-Interventions 
The 2 trial treatments are either RBCs ≤7 days of storage or standard issue RBCs. This period of 
eligibility is the first 7 days after ICU admission. Patients who require a RBC transfusion after 7 
days from ICU admission will not be eligible to participate in the trial. All blood products 
including the RBCs used in this trial will be supplied by the hospital blood bank according to 
local and national regulations.  Only pre-storage leuko-reduced RBC units will be used in this 
trial.  Since RBCs are collected, processed and stored in multiple methods and solutions we will 
record each of these parameters for all RBCs transfused during the intervention period.  Major 
co-interventions including use and volume per kg of all blood products (including frozen plasma, 
platelets, and cryoprecipitate). Other co-interventions that will not be protocolized due to the 
pragmatic nature of the trial but that will be monitored include fluid balance per day, and the 
proportion of patients receiving erythropoietin, vasoactive drugs, mild to moderate hypothermia 
treatment, systemic corticosteroids, insulin, starch colloids and/or gelatins and other events 
(plasmapheresis and Molecular Adsorbent Re-Circulating System or MARS).  Data on these co-
interventions will be collected daily up to 28 calendar days or ICU discharge or death so that the 
effect of any imbalances on the primary outcome can be examined after the trial is completed. 
4.6. Study Participant Duration 
Patients who are randomized remain in either study group for 28 calendar days. All randomized 
patients will be followed for a total of 90 days for both mortality and ICU readmission. All other 
outcomes will be measured within the first 28 calendar days after randomization or until ICU 
discharge or death.  
For CAPD scoring, patients will be evaluated by clinical providers prior to every transfusion and 
twice a day for 72 hours following each transfusion for 28 calendar days post randomization or 
72 hours following the last study transfusion, whichever is latter. 
4.7. Selection and Withdrawal of Patients 
4.7.1. Screening and consent procedures  
Patients will be screened, and consented for randomization via three main scenarios in this trial 
(See figure 2 below; other scenarios may occur): 
1. First scenario: Patients at high risk for RBC transfusion in the ICU.  
a. We will monitor clinical status and laboratory hemoglobin values (see MOP for 

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guidance on determining high risk of transfusion). 
b. Research staff will verify eligibility, inclusion and exclusion criteria. 
c. If patient meets all criteria, consent will be obtained. 
d. Then, if RBC transfusion is ordered in the ICU within first 7 days after admission, 
the patient will be randomized.  
 
2. Second scenario: RBC transfusion is ordered in the ICU when the PICU clinical team is 
involved in the care of a patient: 
a. Research staff will verify, inclusion and exclusion criteria. 
b. If patient meets all criteria, consent will be obtained. 
c. Then, patient will be randomized. 
 
3. Third scenario: Patient for whom ICU admission is requested post-operatively and who 
definitively requires a RBC transfusion intra-operatively: 
a. Research staff will verify eligibility, inclusion and exclusion criteria. 
b. If patient meets all criteria, consent will be obtained pre-operatively. 
c. When RBCs are requested in the OR in preparation for surgery, the patient will be 
randomized.  
Figure 2: Screening, eligibility, consent, and randomization scenarios   
 
In order to detect potential selection bias, a screening log will be maintained at each site to 
record the number of eligible patients who were not randomized and reason for their exclusion. 
Screening and assessment of study eligibility will be reassessed daily for a total of 7 days from 
ICU admission or from the moment the ICU team assumes care responsibilities for the patient.  
This period of eligibility is justified because the rate of New or Progressive MODS is low after 7 
days in ICU (< 2%)46. A patient discharged from ICU and subsequently readmitted after > 24 
hours will be considered a new ICU admission.  Therefore, if a patient is readmitted > 24 hours 
after ICU discharge and has not been previously been enrolled and randomized in the ABC PICU 
Trial he will be eligible for the first 7 days of this new admission.  
Written informed consent will be required prior to randomizing a patient in the ABC PICU Trial. 
Assent should be obtained from the child according to the REB/IRB requirements at each site.  

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4.7.2. Eligibility criteria 
A patient will be entered in the screening log and considered eligible to participate in the trial if 
one of the following occurs: 
1. A first RBC transfusion is requested within the first 7 days (168 hours) of PICU 
admission.  
OR 
2. A patient assessed pre-operatively and for whom ICU admission is planned post-
operatively, and who is determined to definitively require a first RBC transfusion during 
surgery.  
Patients will be considered for randomization if they meet all inclusion criteria and have none of 
the exclusion criteria. 
4.7.3. Inclusion criteria 
Eligible critically ill pediatric patients who have an expected length of stay after transfusion in 
the ICU > 24 hours based on the best judgment of the attending ICU staff. 
4.7.4. Exclusion criteria  
Patients who meet one of the following criteria will be excluded: 
1. Age at time of enrollment < 3 days from birth or has reached their 16th birthday    
2. Post-conception age < 36 weeks at time of enrollment 
3. Documented RBC transfusion within the 28 days prior to fulfilling the eligibility criteria 
4. Previously randomized in this study 
5. Weight < 3.0 kg at ICU admission   
6. Known pregnancy 
7. Conscious objection or unwillingness to receive blood products 
8. Not expected to survive beyond 24 hours, brain death or suspected brain death 
9. Limitation or withdrawal of care decisions have been made 
10. Enrollment in another randomized clinical trial which has not been approved for co-
enrollment 
11. Patients for whom autologous and/or directed donation RBCs will be provided  
12. Patients for whom the treating physician routinely and systematically requests RBC ≤ 14 
days of storage 
13. Patients for whom there systematically exist RBC aliquoting policies that mandate the 
initial use of units stored ≤ 14 days (ex: Pedi-Pack).  
14. On ECMO or plan to be immediately placed on ECMO at time of enrollment 
15. Patient predicted or presumed to require a massive transfusion according to treating 
physician judgment.  
16. Refusal by physician 
17. Inability to obtain consent  
18. Blood bank personnel experiences difficulties in securing blood products (difficult cross 
matches, rare blood groups and diseases like IgA deficiency) 
19. Insufficient number of ABO type compatible RBC units available in the blood bank at 
randomization with a storage time ≤ 7 days (minimum 1 unit regardless of patient age) 
20.  All RBC units available for the patient are not leukocyte-reduced prior to storage 

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Exclusion criteria # 1 to 17 will be ascertained by the research staff with the assistance of the 
attending ICU team. Exclusion criteria # 18 to 20 will be ascertained by blood bank personnel.  
4.8. Duration of treatment period and follow up 
Proposed duration of treatment (study intervention) and follow-up for the primary outcome 
NPMODS is 28 calendar days following randomization or up until ICU discharge or death. 
NPMODS will be monitored daily for the first seven days following randomization and then 
weekly until 28 calendar days or ICU discharge and through ICU stay.  Follow up will occur at 
90 days to determine mortality and ICU readmission rates. 
4.9. Stopping Rules or Discontinuation Criteria 
The stopping rules for the trial will be based upon the interim analysis or due to safety concerns 
as assessed by the DSMB. We are planning to do one interim analysis while conducting the ABC 
PICU Trial once 50% of patients have been accrued. The interim statistical analysis will compare 
NPMODS rates in the “short storage” and the “standard issue” transfusion strategy groups, using 
O’Brien and Fleming’s stopping rules, with a two-tailed p value. The p-values for the 2 looks (1 
interim + 1 final) will be 0.003051 and 0.046946; upper and lower boundaries of these z values 
are ±2.96259 and ±1.96857. The data and safety monitoring board (DSMB) of the ABC PICU 
Trial may consider terminating enrollment if the statistical analysis described above shows a 
statistically significant difference. Both positive and negative findings from the ABC PICU Trial 
will be considered of clinical interest. 
4.10. Patient withdrawal 
Study patients will be able to withdraw from the trial at any time.  The data collected for all 
patients until the time of study withdrawal will be analyzed unless it is requested in writing that 
all data prior to study withdrawal is not to be analyzed. Despite the very low patient withdrawal 
rate expected, secondary analyses will be performed to understand the influence of withdrawals 
on the robustness of the intention-to-treat analysis of our primary outcome. The general 
approaches will include a best-case, worse-case scenario for all patients lost to follow-up or 
voluntarily withdrawing from the study prior to the 28-day follow up period. To accomplish this 
for patients with missing NPMODS data, we will first, in a best-case scenario, assume that none 
developed NPMODS and then, for the worst-case scenario, we will assume that every patient 
with missing NPMODS data did develop NPMODS.  For both scenarios NPMODS will be 
compared between both treatment groups just as described for the primary analysis.  
 
 
 

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4.11. Sample Size 
Patient eligibility criteria 
and short storage definition 
for RBCs in the ABC PICU 
Trial will be similar to those 
used in our preliminary 
studies (Table 1). 43,44 As a 
result we expect the 
incidence of NPMODS and 
estimated Relative Risk 
Reduction (RRR) to be 
accurate based on these prior 
results. When compared to 
our previous studies, the definition of short storage (7 day cut off) is the same in the ABC PICU 
Trial as that in these prior studies. 43,44  ABC PICU Trial inclusion criteria of ICU Length Of 
Stay (LOS) > 24 hours after transfusion is the same it was in the Gauvin study44 (Karam study 
used PICU LOS > 48 hours), whereas the ABC PICU Trial  inclusion of hemodynamically 
unstable patients will be the same as patients in the Karam study43 (Gauvin study only included 
hemodynamically stable patients).  The incidence of NPMODS ranged between 15-39%.  Based 
on these results we have conservatively chosen to use an expected incidence of 18% for 
NPMODS in the control group and 12% in the treatment group for a RRR of 33%. According to 
these estimates, the sample size required for the trial is 1538 participants.  The ABC PICU Trial 
Steering Committee, CCCTG and PALISI Networks support our above estimates and the choice 
of a 33% RRR because it is considered clinically important and sufficiently significant to change 
practice. Sample size calculations were estimated based on the above estimates and the formula 
for two independent proportions (chi-square) using a two-tailed α of 0.05 and a (1-β) of 0.90. 
While we expect that “short storage” RBCs are superior to standard stored RBCs, we cannot rule 
out that it may be inferior and thus have incorporated a conservative two-side alpha.  Minor 
attrition at 1.7% is expected based on results of the TRIPICU study. To account for possible 
randomization failures, a conservative 1.7% non-compliance factor was incorporated in the 
sample size calculation.   
4.12. Recruitment rate 
Conservative assessment of estimated recruitment shows that we can expect to enroll an average 
of 1.5-2 patients per center per month. With up to 30 sites actively recruiting at this rate, the 
ABC PICU Trial patient recruitment will be completed within 36-48 months. We are seeking 
support from several sites in Europe to maximize recruitment. The trial should be completed 
within 5 years including study preparation and data analysis time. 
4.13. Compliance 
4.13.1. Measures to ensure compliance  
The conduct of the trial depends on blood banks dispensing appropriately aged RBCs to patients 
in both study arms. As required, a record of patients actively participating in the ABC PICU 
Trial will be kept at each participating blood bank in order to deliver RBC units with the shortest 
storage time possible to patients in the short storage arm; sites with automated blood bank 
management systems, such as Traceline, will not require this. Several measures will be instituted 
to highlight trial participation and to maximize compliance. We have: 1) ensured full 
Table 1: Estimates for the absolute risk, reduction expected in ABC PICU 
 
RCT 
Gauvin et al 44 
Epidemiologic study – 
Karam et al 43 
RBC storage time cutoff 
7 days 
7 days 
PICU expected LOS 
> 24 hours 
> 48 hours 
Hemodynamic unstable patients 
No 
Yes 
Percentage of NPMODS in all 
transfused patients 
15% 
39.2% 
Odds ratio for development of 
NPMODS in older vs fresher  
(confidence interval) 
1.39 
(0.42-4.61) 
1.54 
(0.80-2.96) 
Estimated risk in experimental group 
1/OR =(p1/(1-p1))/(p0/(1-p0)) 
11% 
22% 

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participation of Transfusion Medicine/blood bank directors by having them as co-site 
investigators, and by including transfusion medicine expertise on all important trial committees; 
2) developed institute-specific protocols for inventory management of RBC units for the trial and 
tracking of patients enrolled in the trial; 3) organized meetings prior to trial initiation at every 
site; 4) in some sites, we will monitor RBC supply to ensure adequate supplies are available for 
randomization; 5) conduct audits on the age of RBCs entered in the system to identify specific 
sites that may have issues to address; 6) implement mechanisms to allow for appropriate RBCs  
(short storage vs. standard issue) to be transferred from other local sites or from blood providers; 
7) sequestered additional RBC units to ensure an adequate supply of  short storage issue units for 
specific blood groups following randomization and allocation of patients to a study arm.  
4.13.2. Compliance with the intervention  
For the purpose of this study, patients in the “short storage” arm of the study will be considered 
adherent to protocol if 80% or more of transfused RBCs were stored ≤ 7 days and they receive 
no RBC unit stored > 14 days during the 28-day period follow-up period. Patients who have 
compliance rate less than 80% will be considered non-compliant and as such will be removed 
from the “per-protocol” primary analysis. The derived proportion will be used in a logistic 
regression model to assess the effect of compliance on outcome. It will rarely occur that a patient 
in the standard issue arm receives “short storage” RBCs; this may happen, for example, if the 
oldest available RBCs in inventory happen to be ≤ 7 days old or in a patient randomized to the 
standard issue arm who requires unplanned cardiac surgery after ICU admission and for whom a 
specific request is made for fresh RBCs (≤ 7 days old). These patients will also be considered as 
non-compliant. The reverse situation, i.e. any patient who goes from the “short storage” arm to 
standard issue arm, will be considered to fulfill criteria of non-adherence to protocol as described 
above.  
A secondary analysis will be conducted on an intent-to-treat basis. Using this approach, patients 
allocated to the standard issue arm who are intentionally or unintentionally moved to the “short 
storage” arm of the study, will be analyzed as being in the standard issue group. We will also 
identify the rationale for the non-compliance in each instance. 
The clinical team can administer any available RBCs regardless of storage time for patients who 
become unstable and have transfusion requirements that do not allow for adherence to the short 
storage arm of the study. The decision to withhold or to withdraw critical care will not be 
considered an exclusion criterion if taken after patient entry in the trial. These cases will be kept 
in the intent-to-treat analysis.  
4.14. Rate of loss to follow-up 
Loss to follow-up is defined as any patient who is lost after randomization, but before data 
analysis is performed, and for whom no information is available on the primary outcome (for 
example, a lost medical record). We will count the number of losses to follow-up.   
It is expected that the number of losses to follow-up will be very low because most patients will 
remain in the ICU or in the hospital during the entire extent of their participation into the trial. 
Therefore, rate of loss to follow-up should be very low, and hospital outcomes should be easy to 
collect. We expect a 1.7% loss-to-follow-up.  Mortality outcomes after hospital discharges will 
be determined by hospital, state or province registries or by telephone/email contact with the 
family.   
However, some dropouts may happen. If there is an imbalance between the number of dropouts 
in both arms, we will undertake a sensitivity analysis, using an intent-to-treat approach and a 

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worst-case scenario where all the surplus in losses and dropouts in one arm will be allocated to 
the other arm. 
4.15. Type and frequency of analyses 
4.15.1. Philosophy of analysis 
As this is an effectiveness trial, all statistical analyses will be based on an intention-to-treat (ITT) 
approach per Appendix 4. All participants randomized will be analyzed according to the 
intervention to which they were allocated, regardless of whether they received it or not. All p 
values will be reported as two-sided. Hypothesis testing for the primary analysis will be carried 
out with an overall level of significance set using a p value < 0.05, taking into account one 
interim analysis. All statistical analysis will be conducted under the supervision of Dean 
Fergusson (epidemiologist and biostatistician, Ottawa Hospital Research Institute) with input and 
collaboration from Thierry Ducruet (biostatistician from the Unité de Recherche Clinique 
Appliquée (URCA) of the Research Centre at Sainte-Justine Hospital) and Kenneth Schechtman 
(Washington University in St-Louis). 
4.15.2. Baseline characteristics 
Baseline characteristics of patients, intervention and co-interventions in both study arms will be 
assessed using frequency distributions and univariate descriptive statistics including measures of 
central tendency and dispersion. This analysis will also include blood storage duration. Means (± 
standard deviation) will be used to report central tendencies of data that can be reasonably 
approximated using a normal distribution, whereas medians (inter quartile ranges) will be used to 
report data with non-normal distributions. Percentages will be reported for categorical data. Any 
clinically relevant imbalances may be considered for adjusted analyses of primary and secondary 
outcomes.  Baseline characteristics will be reported in a table. 
4.15.3. Intervention and co-interventions 
Post-randomization characteristics of our intervention (short storage vs standard issue RBC 
units) and  major co-interventions such as other blood products (platelets, plasma), fluid balance, 
etc) in the two treatment arms will be presented using frequency distributions with measures of 
central tendency and dispersion and analyzed using relative risks & 95% confidence intervals for 
dichotomous data (e.g. proportion transfused with  platelets) and Wilcoxon-Rank Sum tests for 
difference in continuous data (e.g. difference in median platelet use). These characteristics will 
be reported in a table. 
Primary statistical hypothesis 
The principal research question is whether RBC storage time affects outcome in critically ill 
children. The primary outcome measure of the ABC PICU Trial is New or Progressive MODS. 
We hypothesize that transfusion of RBCs stored for ≤ 7 days (compared to standard issue RBCs) 
will result in a reduction in New or Progressive MODS in critically ill children. As compared to 
standard issue RBCs (length of storage 2-42 days) we expect to find that RBCs stored for ≤ 7 
days decrease the incidence of New or Progressive MODS by an ARR of 6% (from 18% to 12%) 
and a relative risk reduction of 33%. 
4.15.4. Analysis of primary outcome 
The analysis of the primary outcome measure will be conducted on an “intent-to-treat” basis with 
all patients randomized in the ABC PICU Trial.  
The principal analysis, i.e. the influence of treatment groups (“short storage” versus standard 

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issue) on the primary outcome, will be compared using an absolute relative risk estimate with 
95% confidence intervals.  
Secondary analyses of the primary outcome include a logistic regression model to further 
elucidate the measure of effect while adjusting for known prognostic risk factors. For adjusted 
models, risk factors such as site, age, co-morbid illnesses, and severity of illness scores will be 
added to all logistic models based on clinical (not statistical) rationale. Continuous risk factors 
(e.g. PRISM III, number of transfusions per patient) will be entered into the models as a 
continuous measure rather than categorical to improve statistical efficiency. Regression 
diagnostics will be performed on all models. Odds ratios will be estimated from coefficients and 
confidence intervals will be constructed using Robbins-Greenlands procedures. We will also 
compare Kaplan-Meier curves using a log rank test followed by proportional hazards modeling 
for NPMODS rates: this analysis will compare the length of time between randomization and 
appearance of NPMODS.  
4.15.5. Analyses of secondary outcome measures and subgroup analyses 
Secondary outcome analyses 
As with our primary outcome, secondary outcome measures will be analyzed by an “intent-to-
treat” approach. The effect of treatment on dichotomous secondary outcomes will be compared 
by calculating absolute relative risks followed by logistic regression procedures to adjust for 
important prognostic risk factors. Continuous outcome measures such as the PELOD score, 
mechanical ventilation and ICU free days, will be analyzed using either parametric procedures 
(independent t test) or non-parametric procedures (Wilcoxon Rank Sum).  
In keeping with our philosophy of study design and analysis used in other large pragmatic peer-
reviewed clinical trials, we have chosen to not adjust for multiple testing, for the nine secondary 
outcomes. The primary rationale is twofold.  First, we have placed considerable effort in 
selecting and defending our primary outcome of NPMODS and our secondary outcomes 
including their clinical importance, biological plausibility, and disease pathway. Our primary and 
secondary outcomes are explicit in the protocol, trial registration and will be made explicit in the 
publication of the trial protocol and primary publication of the results. As such, the number and 
nature of our outcomes are transparent.  
 
Secondly, the choice of adjustment for multiple comparison is not straightforward (investigator 
set vs Bonferroni vs Hochberg vs Hommel etc) and, more importantly, clinicians who interpret 
the results will be confused by results that have different levels of significance presented in the 
publication. Typically high impact journals often dissuade authors from adjusting for multiple 
testing. Rather, it is less confusing to use traditional 5% level of significance (or 95% confidence 
intervals in our case) when presenting secondary and tertiary outcome analyses, subgroup 
analyses, and sensitivity analyses. To address the statistical consequences of not adjusting, we 
will be very transparent in the discussion of the trial results and state that any secondary results 
that have a p-value of < 0.05 should be interpreted with caution. We will also state in the 
manuscript the false positive rate based on the number of secondary outcomes measured. This 
has been our approach with a large number of peer-reviewed, funded, and published clinical 
trials, which have been successfully published in very high impact journals.   
 
Categorical variables including mortality and infectious complications will be analyzed using an 
unadjusted Chi square followed by logistic regression procedures. 
Subgroup analyses 

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Subgroup analyses are planned for the following subgroups of patients according to: 1) severity 
of illness at baseline, as evaluated by the PRISM III score; 2) stable vs unstable patients at the 
time of first transfusion (as defined in the TRIPICU study); 3) ABO type; 4) cardiac surgery 
patients; 5)volume of RBCs transfused in volume / kg (analyzed by quartiles). Subgroup 
analyses also include the stratification subgroup analyses. We will also perform a stratified 
analysis after collapsing cells with small strata. This analysis will include both age and center 
strata. 
The analytic approach used for all subgroup analyses will be the intent-to-treat analysis 
described above for secondary outcome measures. Interactions between treatment group 
subgroup categories specified above will be calculated. Interactions will be assessed by adding 
the treatment, subgroup of interest (categorized), and its interaction term (treatment X subgroup) 
in a logistic regression model. We recognize the limitations of subgroup analyses (low power, 
Type I error, difficulties in interpretation). These analyses will be hypothesis-generating and 
hypothesis-supporting in nature. 
4.15.6. Other statistical analyses and specific considerations 
The issue of multiple transfusions and varying transfusion unit ages. 
The proposed research will determine whether “short storage” RBC units (defined as all units 
stored at most 7 days) reduce the incidence of New or Progressive MODS when compared to 
standard issue RBCs. Multiple transfusions with RBCs of different ages will occur in both 
treatment arms; we expect randomization will balance this between study arms. In spite of this, 
because there will be overlap across the groups defined by randomization according to RBC unit 
storage time, because 7 days is an arbitrary cut-off point, and because some patients will receive 
multiple transfusions, several exploratory analyses will be performed to enhance our 
understanding of the impact of these realities.   
The metric of interest will be the maximum storage time for all transfusions received by the 
patient.  Independent of the group into which a patient was randomized, initial chi square tests 
will use a 7-day cut-off to determine whether the incidence of New or Progressive MODS differs 
according to whether the maximum storage time as defined above is less than or equal to vs 
greater than 7 days. This will be supplemented with logistic regression models that evaluate this 
relationship after adjusting for age, sex, severity of illness as measured by the PRISM III score, 
stable versus unstable baseline status as defined in the TRIPICU study 45, and patient ABO type. 
To facilitate an assessment of whether cut-points other than 7 days are preferable, sensitivity and 
specificity values will be computed for alternative cut-off points.  More generally, the logistic 
models described will be repeated using alternative cut-points, the associated area under the 
ROC curve will be computed for each model, and each ROC curve will be compared statistically 
with the reference curve that uses 7 days as the cut-point. The latter comparisons will be 
performed using PROC LOGISTIC in SAS version 9.2 which contains options that permit the 
statistical comparison of the area under correlated ROC curves. 
Excluded patients. 
A limited analysis will be conducted on all patients meeting inclusion and exclusion criteria but 
who were not randomized, using data in the screening log, in order to see if these patients were 
different than the patients randomized in the ABC PICU Trial. This analysis will only be used to 
describe the excluded patients and highlight differences between patients who were randomized 
and patients who were eligible but not randomized. In doing so, we hope to identify possible 
selection bias and report on the generalizability of our results. 

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Variations of the intervention due to RBC processing methods  
We will record and report blood bank processing methods for each RBC unit in the ABC PICU 
Trial to ensure that they are similar between study groups.  As we include patients from several 
sites in different countries, we will record and report any processing differences. A short survey 
will be sent to the blood bank of all sites that are ready to start enrolling patients to inquire about 
RBC processing in their center that will need to be recorded per randomized patient. The data 
that will be recorded and compared for each patient includes the processing method of whole 
blood to RBCs, preservative solution, irradiation and washing status. It is expected that the 
randomization and stratification process will balance the differences between RBC processing 
methods.  If this is not the case, we will conduct a sensitivity analysis to control for processing 
methods. 
Co-interventions 
Interventions other than transfusions which augment oxygen delivery (such as inotropic agents, 
fluids and vasodilators) will be adjusted for in the analysis if we observe some imbalance in their 
distribution into the two arms of the trial. Using logistic regression, we will assess the effect of 
these co-interventions on outcomes.  
4.15.7. Data collected  
We will collect baseline data both at ICU entry and at randomization. Data collected will include 
PRISM III score, The Cornell Assessment of Pediatric Delirium (CAPD), demographic and 
chronic health status information, and transfusion history. Following randomization we will 
continue to collect CAPD scores 2 times daily and for 72 hours following each transfusion for 28 
days post randomization or 72 hours following the last transfusion whichever is latter. If after 72 
hours following a transfusion a patient continues to score positive for Delirium(>9), we will 
continue to collect scores until the participant returns to baseline or 7 days following transfusion. 
Additionally, we collect data on intervention, co-interventions and outcomes including 28-day 
all-cause mortality, other mortality rates, organ failures and organ support information. Data will 
be gathered through direct patient visits in hospital, medical charts, blood bank databases, 
communication with clinicians such as attending’s and nursing staff as well as family physician 
and family members, and vital statistics registries in each respective jurisdiction. Blood bank 
personnel will provide data on processing method, preservative solution, RBC storage duration 
and CMV status (if available) for each RBC unit.   
Baseline characteristics of patients, intervention and co-interventions in both study arms will be 
assessed as described in section 4.15.2. 
4.15.8. Data Safety Monitoring Board and Interim Analyses 
Selection of DSMB members will be conducted according to NIH-NHLBI guidelines. Decision 
processes will follow both NHLBI and CIHR policy. The DSMB established for the ABC PICU 
Trial will monitor the implementation and safety of this study. NHLBI staff will convene the 
DSMB and provide an executive secretary. The protocol team will report all study related 
information to the FDA since this trial required an IND that has been approved. The US Study 
Coordinator will be responsible for communicating and submitting all required documents to the 
FDA.  
The DSMB will confidentially review interim/cumulative data for evidence of study-related 
adverse events and for quality, completeness, and timeliness. The DSMB will assess compliance 
with study goals for patient recruitment and retention, adherence to protocol, and factors external 
to the study that may impact patient safety or the ethics of the study. The DSMB will also review 

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data regarding reported adverse events and all outcomes.  
The following guidelines are proposed by the study investigators to assist the DSMB in their 
recommendations for suspension or termination: 
• If a safety concern arises, it is expected that the DSMB will recommend suspension of the 
study and will advise the principal investigators, the NHLBI and the CIHR. Safety should not 
be an issue in the standard issue transfusion strategy group (control group), since the standard 
practice will be used in this group. However, safety can be an issue in the short storage 
group, which is not a standard transfusion strategy. NPMODS and mortality rates will be 
closely monitored. 
• If efficacy is shown sooner than expected, i.e. if RBCs ≤ 7 days is better at the time of 
interim analysis, it is expected the DSMB will notify the NHLBI and the CIHR. 
The PIs (Drs. Philip C. Spinella and Marisa Tucci) are responsible for providing the DSMB with 
new safety information relevant to the study. Information about the conduct of the study, any 
adverse events, and study outcomes will be reported to the DSMB by the study statisticians 
(Dean Fergusson and Kenneth Schechtman) using formats approved by the DSMB. The DSMB 
will also receive all protocol revisions, reports, and manuscripts relating to this study. After each 
data evaluation, the DSMB Chair will make recommendations to the Project Officer at the 
NIH/NHLBI and the US Lead Coordinating Center will notify the FDA Regulatory Project 
Manager regarding the continuation, modification, or termination of the trial.  
Meetings: The DSMB will meet prior to the initiation of the study and at a minimum of at least 
every six months or as needed should safety or serious adverse events concerns arise. There will 
be a scheduled DSMB meeting after the completion of the Vanguard Phase. Ad hoc meetings 
may occur at the request of the DSMB members, the Washington University or Sainte-Justine 
Hospital IRB/REB, or the PIs. Meetings are face-to-face, or by telephone conferences, and may 
comprise up to 3 portions:  
The Open Session to discuss general conduct and progress of the study including adverse 
events, patient accrual and follow-up, demographic characteristics of participants, and 
adherence to the study protocol.  This session will be attended by DSMB members, the PIs, 
the study statistician and the selected members of study team by the study PI’s.  
The Closed Session to discuss grouped safety data will be attended by DSMB members and 
the study statistician. Data will be coded such that the intervention and control arms will not 
be identified.  
The Closed Executive Session is to discuss results, make decisions and formulate 
recommendations. At this session, data may be unmasked if necessary at the discretion of the 
DSMB. A quorum of voting members must be present at the Closed Executive Session for 
decisions to be made based upon majority vote.  A quorum is defined as at least 3 voting 
members. A representative of NIH/NHLBI or FDA may attend all meeting sessions of the 
DSMB.  
DSMB Reports: The DSMB Chair will notify the NIH/NHLBI Program Officer and FDA 
Regulatory Project Manager immediately of any critical problems that arise or failure to comply 
satisfactorily with recruitment criteria. The DSMB Chair will prepare a written summary for all 
DSMB meetings, the findings and recommendations, and will submit the report to the 
NIH/NHLBI Program Officer, FDA Regulatory Project Manager and the PIs (Drs. Spinella and 
Tucci) within 2 weeks of the meeting. The PIs are responsible for providing this report to the 
Washington University and Sainte-Justine Hospital IRBs.  

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Interim analysis: We are planning to do one interim analysis while conducting the ABC PICU 
Trial once 50% of patients have been accrued. The interim statistical analysis will compare 
NPMODS rates in the “short storage” and the “standard issue” transfusion strategy groups, using 
O’Brien and Fleming’s stopping rules, with a two-tailed p value. The p-values for the 2 looks (1 
interim + 1 final) will be 0.003051 and 0.046946; upper and lower boundaries of these z values 
are ±2.96259 and ±1.96857. Both efficacy and futility will be analyzed at the interim analysis. 
The course of action regarding continuation of the study will be discussed between the DSMB, 
NHLBI, and protocol team.  
If necessary, the issue of adjusting the sample size will need to be discussed between the DSMB 
and the Principal Investigators since there will be many factors that will influence the feasibility 
of accruing additional patients. At the interim analysis, to determine if the trial has sufficient 
power, the conditional power to detect the hypothesized 33.3% relative risk reduction will be 
computed based on the observed overall event rate (i.e. the two treatment groups combined) at 
the one designated interim monitoring time point. 
 
4.16. 
Adverse Events/ Serious Adverse Events 
Adverse Events: Patient safety is the highest priority in ABC PICU. Unfortunately, events that 
are unintended or unfavorable may occur. These events need to be tracked and reported to ensure 
safety and accurate interpretation of the ABC PICU outcomes. 
 
The ABC PICU Trial will utilize the following definition of a Serious Adverse Event (SAE) for 
collection and reporting events as provided by the NIH NHLBI: 
Serious Adverse Event (SAE) – an adverse event or suspected adverse reaction is considered 
serious if in the review of the investigator or the sponsor, it results in a Grade 4 or 5 adverse 
reaction defined by any of the following: 
a) 
An adverse event, that is life threatening or prolongs the existing hospitalization. (Grade 
4) 
b) Death (Grade 5) 
 
 
 
 
Adverse Events/ Serious Adverse Events that Require Reporting:   
 
The AE/SAE screening starts at randomization and stops after the patient reaches 28 days post 
randomization or 72 hours after the last study transfusion, whichever is later and provided that 
the patient is still in the hospital. The only exception is Transfusion Associated Graft vs Host 
Disease for which screening will occur throughout the hospitalization (even if the hospitalization 
lasts more than 28 calendar days post randomization) 
 
The 11 events listed below will be considered reportable if they are diagnosed after an RBC 
transfusion regardless of grade. This trial utilizes a modified tool to grade the following events 
and is provided in the eCRF instructions. Each is defined in appendix 3 of this document: 
 
.  
1. Hemolytic transfusion reaction  

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2. Major allergic reaction  
3. Transfusion-related acute lung injury (TRALI)  
4. Septic shock  
5. Circulatory overload (also named transfusion-associated cardiac overload or TACO)  
6. Hyperkalemia  
7. Acute Respiratory Distress Syndrome (ARDS)  
8. Nosocomial pneumonia  
9. Deep vein thrombosis   
10. Transfusion Associated Graft vs. Host Disease  
11. Hypocalcemia 
12. Delirium 
Additionally, All Grade 4 or 5 Serious Adverse Events as defined by the CTCAE V.4 will 
be reported in the eCRF according to reporting timelines listed in figure 3 below. 
 
NOTE: A patient’s death per se is not an event, but an outcome. The event which resulted in 
patient’s death must be fully documented and reported without respect of being considered 
treatment-related or not.  
If the rate of related or unexpected SAEs grade 3-5 rate is > 50% per patients enrolled (after 100 
patients enrolled) an interim safety analysis will be required.  
Critically ill children who are transfused RBCs in the intensive care unit have an expected 90-
day mortality rate of 15.2% (95%CI 4-21%).  We anticipate the 90-day mortality rate for 
children enrolled in ABC PICU to be between 4 to 21 %.  Mortality rates will be reported to the 
DSMB every quarter. If we encounter mortality rates of greater than 25% for children enrolled in 
ABC PICU, an interim analysis will be performed and the results will be reported to the DSMB.   
To evaluate the safety of the trial the DMS/DCC staff that is not blinded to treatment arms will 
perform an interim safety analysis for review by the DSMB. 
 
SAE Reporting:  
Grade 1-2 AE’s/SAEs, as listed above, that are expected or unrelated will be reported to the DCC 
via the eCRF within 28 calendar days and local IRB/ERB according to site IRB/ERB policy. 
Grade 1-2 AE’s/SAEs, as listed above, that are unexpected or related will be reported to the DCC 
via the eCRF within 7 days and local IRB/ERB according to site IRB/ERB policy. 
Grade 3-5 AE’s/SAEs, as listed above and ALL Grade 4 SAE’s, that are determined to be 
unrelated or expected will be reported within 48 hours of the event to the DCC via the eCRF and 
to the local IRB/ERB according to site policy.  
Grade 3-5 AE’s/SAEs, as listed above and ALL Grade 4 SAE’s, that are determined to be related 
or unexpected will be reported to the DCC via the eCRF within 48 hours and to the Medical 
Monitor within 48 hours of the event, and the local IRB/ERB according to site IRB/ERB policy. 
Each of these will require documentation of resolution. The DCC will report each of these SAEs 
to the NHLBI who will forward them to the DSMB Chair.  

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Figure 3 AE/SAE Reporting Timelines: 
 
 
 

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5.  Security  
5.1. Compliance to Privacy-Security Regulations 
Management activities will ensure that privacy and security regulations are defined and followed 
for all participating centers. For example, privacy legislation in Canada occurs at the provincial 
and federal levels. The Ontario provincial legislation (PHIPA) is deemed as substantially similar 
legislation and overrides the federal legislation (Personal Information Protection and Electronic 
Document Act PIPEDA) within the Province of Ontario and HIPAA in United States. Privacy 
issues also relate to the flow of data between a participating site, the DMS and the ICC/USCC. 
DMS will comply with guidelines concerning organizational, technological and physical 
environments. Access to data and preferred approaches will be established. Also a risk 
management approach will be taken to protect research data from loss, corruption, theft or any 
other unauthorized disclosure.   
5.2. Establishment of Coding 
Confidentiality is also part of standard operating procedures. Coding standards will be developed 
by ABC PICU Trial relevant staff, with the participation of the DMS group, in order to 
implement these standards throughout the eCRF.  
Security (Authentication) 
Processes, procedures and more importantly technical methods will be implemented to protect 
information contained in the Web-based application. A secure registration process and tool for 
application authentication will be implemented. Access to data will be provided in a secure and 
reliable manner. Safeguards for network and access will protect data in transit to authorized 
locations. Data will be monitored to prevent its unauthorized dissemination.  
Data safety is maximized through several different mechanisms: physical access to computers 
and servers is electronically protected; server is behind a firewall; server is exclusively dedicated 
to database management (i.e. accessible only for researchers); access is controlled by keywords 
that are changed periodically; daily back-up of the full database and storage at 2 different 
locations will be made. Each center will have access to the data of its own patients, but not to the 
data of patients from other sites participating in the ABC PICU Trial. The data and clinical 
coordinating centers will have access to data from all centers. 
Network Security 
Network security will be performed with the involvement of various IT departments at OHRI, 
Ottawa Hospital, and remote site locations. Network security is used to minimize the risk of 
intrusion, virus infection and any danger arising from malicious software. On-going monitoring 
and maintenance of the network and its access will be provided for the duration of the 
development and the usage of the electronic applications. 
SSL Certificate 
With the implementation of a web application, a Secure Socket Layer (SSL) certificate will 
secure the online communications and transactions for all users accessing the application. The 
certificate will be purchased from a third party SSL certificate vendor, such as Entrust. 
(www.entrust.net) 
5.3. Study monitoring and study organization 
Approval for use of this protocol by the Institutional Review Board (IRB) must be obtained in 

Study Protocol 
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Amendment 2.1 
No. ABC PICU 
 
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20
accordance with the institutional assurance policies of the U.S. Department of Health and Human 
Services. Institutional Review Board (IRB) approval of the ABC PICU protocol and consent 
forms will be required prior to patient participation on the trial. All reasonable measures will be 
taken to protect the confidentiality and identity of the patient and patient’s records according to 
the applicable regulations. Patient identity will not be revealed in any publication.   
5.4.  Study Monitoring  
Data management will include an audit trail, a security system, query functionality and quality 
control done according ICH-GCPs and US CFRs. Data management will be performed at the 
Ottawa Health Research Institute under the supervision of study statistician.  Data will be entered 
on site in the web-based eCRF. For validation purposes only, double data entry will be used. 
During the validation phase, CRF and entries will be considered adequate if the frequency of 
discordance is lower than 2% in the eCRF. In addition, 5-10% of source documents from each 
site will be reviewed by a trained clinical monitor. The DCC will be responsible for data quality 
assurance done through eCRF (via regular data extraction) and queries. 
Each site involved in ABC PICU will experience up to three routine site visits over the course of 
the study.  Coordinators from the ICC will visit sites in Canada, and the USCC Coordinators will 
visit sites in the US. The first routine site visit should occur after the randomization of the first 2-
3 patients (as logistics allow).  The purpose of a routine site visit is to facilitate the site PI and 
Coordinator in carrying out the responsibilities necessary for the completion of the ABC PICU 
Trial.  Site visits are viewed as a supportive measure with the opportunity to educate, not a 
punitive act. 
A for cause site visit will result if a major protocol violation has occurred at the study site.  
The site visit team will review study documents to determine whether the study has been 
conducted according to the protocol and that the inclusion and exclusion criteria were followed 
when enrolling patients. They will also be evaluating for signed documentation stating the 
family/patient was enrolled in the study, and that the consenting process took place per protocol 
and local policies.  The site visit team will also visit the blood bank to assess procedures related 
to maintaining proper inventory and to ensure that staff training is properly documented.   
5.5. Study Organization and Committee Responsibilities  
5.6. Study organization and Committee responsibilities are described in the MOP.  

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21 
6. Appendix 1: Data collection timeline 
 
Hospital 
Admission 
ICU 
Admission 
Just prior 
Randomization 
Day 1 / 
randomization 
Day 2 to 
Day 7 
Day 14 or ICU 
discharge 
Day 21 
or ICU discharge 
Day 28 (end of 
Calendar Day)  
Day 
90 
ICU 
Discharge 
Hospit
Dischar
Inclusion/exclusion 
 
 
X 
 
 
 
 
 
 
 
 
Consent 
 
 
X 
 
 
 
 
 
 
 
 
Demographic 
 
 
X 
 
 
 
 
 
 
 
 
Baseline 
 
 
X 
 
 
 
 
 
 
 
 
PRISM III 
 
X 
 
X 
 
 
 
 
 
 
 
PELOD 2* 
 
X 
X 
 
 
 
 
 
 
X 
 
NPMODS** 
 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
CAPD*** 
 
 
X 
X 
X 
 
 
 
 
 
 
Clinical Data 
 
 
 
X 
X 
X 
X 
X 
 
 
 
Fluid Balance  
 
 
 
Daily from randomization to Day 28 or ICU Discharge  (whichever comes first) 
 
 
 
Co-Interventions (Blood 
products and other therapies)   
 
 
 
Daily from randomization to Day 28 or ICU Discharge (whichever comes first) 
 
 
 
6.1.1. PRBC Transfusion 
documentation and 
information 
 
 
 
6.1.2. X  
All transfusions should be documented through Day 28 (End of calendar 
day) or hospital discharge. If patient is discharged from ICU the patient 
remains on study treatment arm until end of calendar day 28 and all 
transfusion information is documented. 
 
 
 
Nosocomial infections, Sepsis 
and other clinical outcomes 
 
Daily from ICU admission to Day 28 or ICU Discharge (whichever comes first) 
 
 
 
Mechanical ventilation 
 
Daily from ICU admission to Day 28 or ICU Discharge (whichever comes first) 
 
 
 
Vasoactive and/or inotropic 
continuous intravenous drug 
 
Daily from ICU admission to Day 28 or ICU Discharge (whichever comes first) 
 
 
 
Renal replacement therapy 
 
Daily from ICU admission to Day 28 or ICU Discharge (whichever comes first) 
 
 
 
6.1.3. Adverse Events / 
Serious Adverse Events 
 
Daily from randomization to Day 28 or 72 hours after the last study transfusion, whichever is later, provided that 
the patient is still in the hospital. 
 
 
 
Mortality status 
 
 
 
 
 
 
 
 
X 
 
X 
Readmission information^ 
 
 
 
 
 
 
 
 
X 
 
 
Discharge status 
 
 
 
 
 
 
 
 
 
X 
X 
*In addition to the times listed in this table, PELOD 2 score data will be collected on days 2, 5, 8, 12, 16 and 18 after ICU admission 
**In addition to the times listed in this table, NPMODS data will be collected on the days when PELOD 2 data are collected 
*** CAPD scores will be collected immediately prior to transfusion, and 2x daily at the beginning of each nursing shift for 72 hours following each transfusion

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7. Appendix 2: Participating Institutions and Principal Investigators 
7.1. Part A: US Sites 
Critical Care  
Transfusion Medicine 
 
Kenneth Remy, MD 
Washington University School of Medicine 
Pediatric Critical Care Medicine 
660 S. Euclid, CB 8116 
St. Louis, MO  63110 
 
Remy_K@kids.wustl.edu 
Office:  314-286-2894 
 
Ronald Jackups, MD 
Washington University School of 
Medicine 
Laboratory Medicine 
660 S. Euclid, CB 8118 
St. Louis, MO  63110 
 
rjackups@path.wustl.edu  
Office:  314-362-8413 
Matthew Paden, MD 
Children's Healthcare of Atlanta 
Emory University 
Pediatric Critical Care Medicine 
1405 Clifton Road NE 
Atlanta, GA 30322-1060 
matthew.paden@choa.org  
Office: 404-785-1600 
Cassandra Josephson, MD 
Children's Healthcare of Atlanta 
Emory University 
Transfusion Medicine 
1405 Clifton Road NE 
Atlanta, GA 30322-1060 
cjoseph@emory.edu  
Office: 404-785-4553 
Julie C. Fitzgerald, MD 
The Children’s  Hospital of Philadelphia 
Pediatric Critical Care Medicine 
34th Street and Civic Center Blvd 
7th Floor, Main Hospital 
Philadelphia, PA  19104-4399 
fitzgeraldj@email.chop.edu  
Office: 215-590-4879 
Deborah A. Sesok-Pizzini, MD 
The 
Children’s 
Hospital 
of 
Philadelphia 
Transfusion Medicine 
34th Street and Civic Center Blvd 
5136 Main Hospital 
Philadelphia, PA  19104-4399 
pizzini@email.chop.edu  
Office: 215-590-0369 
Caroline Ozment, MD 
Duke University 
Pediatric Critical Care Medicine 
2300 Erwin Road, DUMC 3046 
Durham, North Carolina  27710 
caroline.ozment@duke.edu  
Office:  919-681-5226 
Nick Bandarenko, III, MD 
Duke University Medical Center 
Transfusion Medicine  
2300 Erwin Road, DUMC 2928 
Durham, NC  27710 
nick.b@duke.edu  
Office:  919-681-4666 
Jill Cholette, MD 
Golisano Children’s Hospital at Strong 
Division of Critical Care Medicine 
601 Elmwood Avenue, Box 667 
Rochester, NY  14642 
Jill_Cholette@URMC.Rochester.edu  
Office: 585-276-8138 
Neil Blumberg, MD 
University of Rochester Medical 
Center 
Transfusion Medicine 
601 Elmwood Avenue, Box 608 
Rochester, NY  14642 
neil_blumberg@urmc.rochester.edu  
Office:   585-275-9656 

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Critical Care  
Transfusion Medicine 
 
Michelle Adu-Darko, MD 
University of Virginia Health System 
UVa Children’s Hospital 
Pediatric Critical Care Medicine 
PO Box 800-386 
Charlottesville, VA  22908-0386 
 
Office: 434-083-1707  
James Gorham, MD 
University of Virginia Health System 
Division of Laboratory Medicine/Clinical 
Laboratories 
PO Box 800214 
Charlottesville, VA  22908-0214 
 
Office: 434-982-0145 
 
 
Tim Stidham, MD 
The Children’s Hospital and  
University of Colorado Denver School of 
Medicine 
Pediatric Critical Care Medicine 
13123 East 17th Avenue 
Aurora, CO  80045-7106 
 
Timothy.Stidham@childrenscolorado.org 
Office: 303-724-2393  
 
Kelley E. Capocelli, MD 
Children’s Hospital Colorado 
Transfusion Medicine 
13123 East 16th Avenue 
Aurora, CO  80045 
 
kelley.capocelli@childrenscolorado.org  
Office:  720-777-6718 
 
Jennifer Muszynski, MD 
Nationwide Children’s Hospital 
Pediatric Critical Care Medicine 
700 Children’s Drive 
Columbus, OH  43205 
 
Jennifer.muszynski@nationwidechildrens.org 
Office:  614 722-4565  
 
Kathleen Nicol, MD 
Nationwide Children’s Hospital 
Department of Pathology & Lab Medicine 
700 Children’s Drive 
Columbus, OH  43205 
 
kathleen.nicol@nationwidechidlrens.org  
Office:  614-722-5301 
 
 
 
 
 
 
 

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Critical Care  
Transfusion Medicine 
 
Erika L. Stalets, MD 
Cincinnati Children’s Hospital Medical Center 
Pediatric Critical Care Medicine 
3333 Burnet Avenue, MLC 2005 
Cincinnati, OH  45229-3039 
 
erika.stalets@cchmc.org  
Office:- 513-636-4854  
 
Patricia M. Carey, MD 
Hoxworth Blood Center 
3130 Highland Avenue 
PO Box 670055 
Cincinnati, OH  45267-0055 
 
patricia.carey@uc.edu  
Office: 513-558-1338 
 
Michael Hobson, MD 
James Whitcomb Riley Hospital for Children 
Pediatric Critical Care Medicine 
Indiana University 
702 Barnhill Drive, RDC 4270 
Indianapolis, IN  46202-5128 
 
mjhobson@iu.edu  
Office:  317-274-7208  
 
Daniel Smith, MD 
Indiana University Health 
Department of Laboratory Medicine 
350 West 11th Street, Room 5006C 
Indianapolis, IN 46202-4108 
 
dsmith21@iuhealth.org  
Office:   
 
Jerry J. Zimmerman, MD 
Seattle Children’s Hospital 
Pediatric Critical Care Medicine 
Room W8866 
4800 Sand Point Way NE 
Seattle, WA  98105-0391 
 
jerry.zimmerman@seattlechildrens.org  
Office:  206-987-3862  
 
Meghan Delaney, DO 
Puget Sound Blood Center 
921 Terry Avenue,  
Seattle, WA  98104 
 
meghand@psbc.org 
Office 206-233-3330 
 
Sheila Hanson, MD 
Children’s Hospital of Wisconsin 
Pediatric Critical Care Medicine 
9000 West Wisconsin Avenue, MS 681 
Milwaukee, WI  53226-4874 
 
shanson@mcw.edu  
Office: 414-266-3360  
 
Rowena Punzalan, MD 
Blood Center of Wisconsin 
638 N 18th Street, PO Box 2178 
Milwaukee, WI  53226-2121 
 
rowena.punzalan@bcw.edu  
Office: 414 257-2424 
 
 
 
 
 
 

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Critical Care  
Transfusion Medicine 
 
Peter Luckett, MD 
Children’s Medical Center Dallas 
Division of Critical Care Services 
1935 Medical District Drive 
Dallas, TX  75390-9063 
 
PETER.LUCKETT@childrens.com 
Office:  214-456-7769 
 
Daniel Noland, MD 
Children’s Medical Center Dallas 
UT Southwestern Medical Center 
Transfusion and Tissue Service 
5323 Harry Hines Blvd 
Dallas, TX  75390-9063 
 
daniel.noland@childrens.com  
Office:  
 
Patrick McQuillen, MD 
University of California, San Francisco 
1550 4th Street, Room 384E 
San Francisco, CA  94143-0106 
 
saprua@peds.ucsf.edu  
Office: 415-502-4798 
 
Stacy Gikas 
University of California, San Francisco 
Department of Laboratory Medicine 
505 Parnassus Avenue, M-501 B 
San Francisco, CA  94143-0100 
 
Anastasia.Gikas@ucsf.edu 
Office: 415-353-1311 
 
Margaret Winkler, MD 
University of Alabama at Birmingham 
Pediatric Critical Care Medicine 
CPPI 102 
1600 7th Avenue South,ACC #504 
Birmingham, AL 35223-1711 
 
 
mwinkler@peds.uab.edu 
Office: 205 939-9387 
 
Dava Sue Cleveland, DO 
Children’s of Alabama 
Department of Pathology and Laboratory 
Medicine 
1600 7th Avenue South 
Birmingham, AL  35233 
 
dava.cleveland@childrensal.org  
Office: 205-558-2912 
 
Barry Markovitz, MD 
Children’s Hospital Los Angeles 
Critical Care Medicine 
4650 Sunset Blvd., MS #12 
Los Angeles, CA  90027 
 
bmarkovitz@chla.usc.edu  
Office: 323-361-2557 
 
 
Ajay Perumeti, MD 
Children’s Hospital Los Angeles 
Transfusion Medicine 
4650 Sunset Blvd. 
Los Angeles, CA  90027 
 
Aperumbeti@chla.usc.edu 
Office :  323 361-5667 
 
 
 
 
 
 
 

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26
Critical Care  
Transfusion Medicine 
 
Laura Loftis, MD 
Baylor College of Medicine 
Section of Pediatric Critical Care Medicine 
Texas Children's Hospital 
6621 Fannin, WT-6-006 
Houston, TX  77030 
 
lloftis@texaschildrens.org  
Office: 832-826-6213 
 
Jun Teruya, MD 
Baylor College of Medicine 
Division of Transfusion Medicine and Coagulation 
Texas Children's Hospital 
6621 Fannin St, Suite WB1100 
Houston, TX 77030-2303 
 
jteruya@bcm.edu  
Office:  832-824-1879 
 
Adam J. Schwarz, MD 
Pediactric Critical Care Medicine 
1201 W La Veta Avenue 
Orange, CA 92868 
 
 
aschwarz@choc.org 
Office: 714 509-8620 
 
Pirooz Behpoor 
Supervisor, Blood Bank 
1201 W La Veta Avenue 
Orange, CA 92868 
 
pbehpoor@choc.org 
714 509-9006 
 
Marie Steiner, MD 
University of Minnesota 
Pediatric Hematology-Oncology 
Mayo Mail Code 484 
420 Delaware Street, SE 
Minneapolis, MN  355455 
 
stein083@umn.edu  
Office:  612-626-2778 
 
Nicole Zantek, MD 
University of Minnesota 
Laboratory Medicine and Pathology 
Mayo Mail Code 609 
420 Delaware Street, SE 
Minneapolis, MN 55455 
 
zant0005@umn.edu 
Office:  612-626-3768 
 
 
Joel Cochran, DO 
The Medical University of South Carolina 
Rutledge Tower 
135 Rutledge Avenue 
Charleston, SC  29425 
 
cochrajb@musc.edu  
Office:  843-792-2618 
 
Jerry Squires, MD 
The Medical University of South Carolina 
165 Ashley Avenue, EH208A3 
Charleston, SC  29425 
 
squiresj@musc.edu 
Office:  843-792-4150 
 
Kevin Kuo, MD 
University of Michigan Medical School 
CS Mott Children’s Hospital, F6790/5243 
1500 East Medical Center Drive 
Ann Arbor, MI  48109-5243 
 
kkevin@med.umich.edu 
Office: 510 499-9614 
 
Robertson Davenport, MD 
University of Michigan Health System 
UH 2G332 
1500 E. Medical Center Drive 
Ann Arbor, MI  48109-5054 
 
rddvnprt@umich.edu 
Office:  734-936-6776 
 
 
Critical Care  
Transfusion Medicine 

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27
 
Doug Willson, MD 
Medical College of Virginia 
Children’s Hospital of Richmond 
Old City Hall 
1001 E. Broad Street, 2nd Floor, Suite 205A 
Richmond, VA  23219 
 
dwillson@mcvh-vcu.edu 
Office: 804 828-4529 
 
Kim Sanford, MD 
Virginia Commonwealth University, Department 
of Pathology 
The Gateway Building, 6th Floor 
1200 East Marshall Street, PO Box 980231 
Richmond, Virginia 23298-0662 
 
ksanford@mcvh-vcu.edu 
Office:  804-828-2745 
 
Leslie Avery, MD 
University of Florida, UF Health Shands Children’s 
Hospital 
1600 SW Archer Rd 
Gainesville, FL 32610 
 
avery4@ufl.edu 
Office:  702-343-0301 
 
 Joseph Peter Ray Pelletier, MD 
University of Florida, UF Health Shands 
Children’s Hospital 
Department of Pathology 
1600 SW Archer Rd 
PO BOX 100275 
Gainesville, FL 32610 
 
pelletierp@ufl.edu 
Office:  352-256-0488 
 
Arun Saini, MD 
University of Tennessee  
Le Bonheur Children’s Hospital 
50 N. Dunlap St. 3rd Floor 
Memphis, TN 38103 
 
cochrajb@musc.edu  
Office:  843-792-2618 
 
University of Tennessee 
Le Bonheur Children’s Hospital 
 
 
 
 
 
Kris Bysani, MD 
Medical City Children’s Hospital 
7777 Forest Lane Suite D569 
Dallas, TX 75230 
 
cochrajb@musc.edu  
Office:  972-566-8340 
 
Michael Newhouse 
Medical City Children’s Hospital 
Carter Blood Care at Medical City Dallas 
7777 Forest Lane 
Dallas, TX 75230 
 
mnewhouse@carterbloodcare.org 
Office: 972-566-4910 
 
 

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28
 
 
Katri Typpo, MD, MPH, FAAP 
University of Arizona, Health Sciences Center 
Diamond Children's Medical Center 
1501 N. Campbell Avenue 
 
ktyppo@email.arizona.edu 
520-626-5485 
 
Maria Proytcheva, MD 
University of Arizona, Health Sciences Center 
Diamond Children's Medical Center 
Department of Pathology 
P.O. Box 245059 
1501 N. Campbell Avenue 
Tucson, AZ 85724 
 
Maria.Proytcheva@bannerhealth.com  
Office: 520-694-7329 
 
Lauren Marsillio, MD 
Ann & Robert H. Lurie Children’s Hospital of 
Chicago 
Box 73 
Chicago, IL 60611 
 
LMarsillio@luriechildrens.org 
Office: 312-227-5296 
 
Maria Samuels 
Ann & Robert H. Lurie Children’s Hospital of 
Chicago 
225 E. Chicago Ave, 
Chicago IL 60611 
 
LMSamuels@luriechildrens.org 
Office: 773-880-6632 
 
Marianne Nellis, MD, MS 
Division of Pediatric Critical Care Medicine 
Weill Cornell Medical College 
525 East 68th St, M-508 
New York, NY 10065 
 
man9026@med.cornell.edu 
Office: 212-746-3056 
 
Melissa Cushing, MD 
Director of Transfusion Medicine and Cellular 
Therapy 
Weill Cornell Medical College 
New York Presbyterian Hospital 
 
 
mec2013@med.cornell.edu 
Office:  212-746-3527 
 
Maureen Quaid, MD  
Advocate Children’s Hospital  
1775 Dempster Street  
Park Ridge, IL 60068  
 
Maureen.quaid@advocatehealth.com  
Office: 847 723-7682  
Nicole Roggeman 
Advocate Children’s Hospital 
1775 Dempster Street, 5th Floor 
Park Ridge, IL 60068 
 
nicole.roggeman@advocatehealth.com 
Office: 847 723-5584 
 
 

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29
 
7.2. Part B: Canadian Sites 
Critical Care  
Transfusion Medicine 
 
 
 
 
 
Guillaume Emeriaud, MD 
CHU Sainte-Justine, Centre de recherche  
3175 Chemin de la Côte Sainte-Catherine 
  
Montréal  (QC), Canada 
H3T 1C5 
 
guillaume.emeriaud.hsj@ssss.gouv.qc.ca 
  
Office :  514 345-4931 x3316 
 
Nancy Robitaille, MD 
CHU Sainte-Justine 
3175 Cote-Sainte-Catherine 
Montréal  (QC), Canada 
H3T 1C5 
 
nancy.robitaille@umontreal.ca  
Office:   
 
Marc-André Dugas, MD 
Centre Hospitalier de l’Université Laval (CHUL) 
2705, boulevard Laurier 
Québec, QC, G1V 4G2 
 
marc-andre.dugas@mail.chuq.qc.ca  
Office:   418 654-2282 
 
Pierre Ouellet, MD 
Centre Hospitalier de l’Université Laval (CHUL) 
2705, boulevard Laurier 
Québec, QC, G1V 4G2 
 
pierre.ouellet@chuq.qc.ca  
Office :   
 
Kusum Menon, MD 
Children’s Hospital of Eastern Ontario (CHEO) 
401 Smyth Road 
Ottawa, ON, K1H 8L1 
 
menon@cheo.on.ca  
Office:  613 737-7600 #3670 
 
 
Elaine Leung, MD  
Children’s Hospital of Eastern Ontario (CHEO) 
401 Smyth Road 
Ottawa, ON, K1H 8L1 
 
ELeung@cheo.on.ca  
Office:   
Jamie Hutchison, MD 
The Hospital for Sick Children 
555 University Avenue 
Toronto, ON, M5G 1X8 
 
jamie.hutchison@sickkids.ca  
Office :  416  813-6477 
Wendy Lau, MD 
The Hospital for Sick Children 
555 University Avenue 
Toronto, ON, M5G 1X8 
 
wendy.lau@sickkids.ca  
Office :   
 
Karen Choong, MD 
Hamilton Health Sciences 
McMaster University Medical Centre  
McMaster Children's Hospital 
1200 Main Street West  
Room 3 A 78 
Hamilton, ON, L8N 3Z5  
 
choongk@mcmaster.ca  
Office:  905 525-9140 
 
Anthony Chan, MD 
Hamilton Health Sciences 
McMaster University Medical Centre  
McMaster Children's Hospital 
1200 Main Street West  
Hamilton, ON, L8N 3Z5  
 
akchan@mcmaster.ca 
  
Office:   

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30
 
Amrita Sarpal, MD 
London Health Sciences Centre 
Children’s Hospital 
800 Commissioners Road East  
London, ON, N6A 5W9 
 
 
Office :   
 
Cyrus C. Hsia, MD 
London Health Sciences Centre  
Children’s Hospital 
800 Commissioners Road East  
London, ON, N6A 5W9 
 
Cyrus.Hsia@lhsc.on.ca   
Office:  519-685-8500 ext. 56060 
 
Gonzalo Guerra, MD 
Stollery Children's Hospital 
Office 3A3.07 Walter C Mackenzie Center 
8440, 112 Street 
Edmonton, AB, T6G 2B7 
 
Gonzalo.Guerra@albertahealthservices.ca 
 
Office:  780 407-1673 
 
Susan Nahirniak, MD 
Stollery Children's Hospital 
8440, 112 Street 
Edmonton, AB, T6G 2B7 
 
snahirni@cha.ab.ca  
Office :   
 
 
David Wensley, MD 
British Columbia’s Children's Hospital 
4480 Oak Street 
Room 2L5 
Vancouver, BC, V6H 3V4 
 
dwensley@cw.bc.ca  
Office :   
 
Nicholas Au, MD  
British Colombia’s Children's Hospital 
4480 Oak Street 
Room 2K50 
Vancouver, BC, V6H 3V4 
 
nau2@bccancer.bc.ca  
Office :   
 
7.3 Part C: Sites in Europe and Israel 
Critical Care  
Transfusion Medicine 
 
 
 
 
Théophile Gaillot, MD 
CHU Pontchaillou 
2 rue Henri Le Guilloux  
35033 Rennes cedex 9 
 
theophile.gaillot@chu-rennes.fr 
Office: +33 (0)2 99 26 58 85 
 
 
Julie Vasse, MD 
Établissement Français du Sang 
Rue Pierre Jean Gineste 
35016 Rennes 
 
julie.vasse@efs.sante.fr   
Tel : +33 (0)2 99 54 42 22 
 
 Stéphane Leteurtre, MD   
Hôpital Jeanne de Flandre 
Avenue Eugène Avinée 
59037 Lille Cedex 
 
stephane.leteurtre@chru-lille.fr 
Office: +33 (0)3 20 44 68 79 
 
 Erice Resch, MD 
Etablissement Français du Sang 
95 Rue Jemmapes 
59800 Lille 
 
eric.resch@efs.sante.fr  
Tel : +33 (0)3 28 54 20 30 

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31
 
 
 
  Nicolas Joram, MD 
Réanimation pédiatrique 
Hôpital Mère Enfant 
38 boulevard Jean-Monnet 
44093 Nantes cedex 1 
 
Nicolas.JORAM@chu-nantes.fr  
   Tel : +33 (0)2 40 08 34 83 
 
 
 
Catherine David, MD 
Établissement Français du Sang 
34 bd Jean Monnet 
44011 Nantes 
 
catherine.david@efs.sante.fr  
 Tel : +33 (0)2 41 72 44 41 
Frabrizio Chiusolo MD  
Bambino Gesu Children’s Hospital  
Department of Anesthesia and  
Rome Italy Piazza S.Onofrio  
Rome Italy 
 
fabrizio.chiusolo@opbg.net  
Office: 390687788934  
Mauro Montanari, MD 
Bambino Gesu Children’s Hospital 
Director, Immunochematology and Transfusion 
Piazza S. Onofrio 4, 00165  
Rome Italy 
 
mauro.montanari@opbg.net 
Office: 390668594771 
Gidi Paret, MD, MHA  
Director, Dept of Pediactric ICU  
The Chaim Sheba Medical Center  
Tel Hashomer 32621  
Israel 
 
gparet@post.tau.ac.il  
Office: 972-3-5302885  
Mathilda Mandel, MD, MHA 
Transfusion Medicine 
The Chaim Sheba Medical Center 
Tel Hashomer 5265601 
Israel 
 
mmandel@post.tau.ac.il 
Office: 972-3-5304081 
 
 

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8. Appendix 3: Definitions of AE’s/SAEs 
 
1. 
Hemolytic transfusion reaction – requires presence of hemoglobinuria or 
hemoglobinemia, new or unexplained by underlying condition, observed from the beginning 
of the transfusion up to 4 hours after end of the transfusion. 
1.1. 
Hemoglobinuria:   macroscopic or microscopic hemoglobinuria, red, pink or very 
dark urine with positive test for hemoglobin in urine, observed from the beginning of 
the transfusion up to 4 hours after it was completed 
1.2. 
Hemoglobinemia:  blood level of free hemoglobin above normal range or positive 
direct Coombs test (also know as the direct antiglobulin test or DAT) 
1.3. 
At least one of the following symptoms/signs. 
1.3.1. Fever (> 38°C) de novo. 
1.3.2. Dyspnea de novo. 
1.3.3. Hypotension and/or tachycardia de novo. 
1.3.4. Anxiety/agitation de novo. 
1.3.5. Pain de novo. 
2. 
Major allergic reaction - A disorder characterized by an adverse local or general response 
(Type 1 hypersensitivity reaction47) from exposure to an allergen that includes at least 1 of 
the following: 
2.1. 
Cardiac Arrest 
2.2. 
Generalized allergic reaction or anaphylactic reaction de novo 
2.3 
Angio-edema (facial and/or laryngeal) de novo (as reported by nurses). 
2.4 
Upper airway obstruction de novo. 
2.5 
Dyspnea de novo, wheezing de novo. 
2.6 
Hypotension de novo, shock de novo. 
2.7 
Precordial pain or chest tightness de novo. 
2.8 
Cardiac arrhythmia de novo. 
2.9 
Loss of consciousness de novo. 
3. Transfusion-related acute lung injury (TRALI) – TRALI is caused de novo by a 
transfusion, and appearing during or less than 6 hours after the end of a transfusion.   
3.1 
New onset or worsening of pulmonary function with hypoxemia that satisfies the 
international criteria for ALI (PaO2/FiO2 <300 mm Hg) 
AND 
3.2 
Chest x-ray consistent with pulmonary edema  
4 
Septic shock – Septic Shock is defined as sepsis with cardiovascular dysfunction. Sepsis is 
defined as SIRS in the presence of or as a result of suspected or proven Infection. 

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SIRS requires the presence of at least two of the following four criteria, one of which must 
be abnormal temperature or leukocyte count 
(see section 1.2 of the Sepsis worksheet) 
 
There are 4 criteria for SIRS: 
4.1 
Core temperature > 38.5°C or <35°C. 
Note that core temperature must be 
measured by rectal, bladder, oral or 
central catheter probe. 
4.2 
Leukocyte count elevated or depressed 
for age (not secondary to chemotherapy 
induced leucopenia) or > 10% immature 
neutrophils (bands) (Table 2) 
4.3 
Heart Rate: 
4.4 
Tachycardia, defined as: mean heart rate above the 95th percentile for age in the 
absence of external stimulus, chronic drugs, or painful stimuli (Table 3) 
OR 
4.5 
Otherwise unexplained persistent elevation over a 0.5 to 4 hour time period. 
Unexplained refers to elevated heart rate 
not explained by obvious or known cause 
such as crying, agitated, administration of 
drugs causing elevated heart rate 
(atropine), etc.  
OR 
4.6 
Bradycardia for children <1 yr old, 
defined as:  Mean heart rate <10th 
percentile (Table 4)   
OR 
4.7 
Otherwise unexplained persistent 
depression of the HR over a 0.5 time 
period. Unexplained refers to bradycardia 
not explained by obvious or known cause 
such as administration of beta-blocking 
agent, significant hypothermia, known 
intrinsic dysfunction of the heart’s 
electrical conduction system 
(atrioventricular bloc, sinus bradycardia). 
 
 
 
 
 
 
 
 
 
 
Table 2 
5th and 95th percentile for leukocyte count48 
Age 
Leukocyte Count 
0 days – 1 week 
>34 
1 week to 1 month 
>19.5 or <5 
1 month to 1 year 
>17.5 or <5 
2 – 5 years 
>15.5 or <6 
6 – 12 years 
>13.5 or <4.5 
13 – 18 years 
>11 or <4.5 
Leukocyte Count (103 / mm3 = K/Cumm = 
109/L) 
Table 3: 
95th percentile values for heart rate in children49 
Age  
Beats/minute 
0 days – 1 week 
154 
1 week to 1 month 
159 
1 -3 months 
169 
3 – 6 months 
164 
6 - 9 months 
157 
9 – 12 months 
151 
12 – 18 months 
147 
19 – 24 months 
144 
2 – 3 years 
141 
3 – 4 years 
138 
4 – 6 years 
135 
6 – 8 years 
133 
8 – 12 years 
131 
12 – 15 years 
130 
15 – 18 years  
129 
Table 4:  10th percentile for heart (HR) in 
children < 1 year49 
Age  
Beats/minute 
0 – 3 months 
123 
3 – 6 months 
120 
6 – 9 months 
114 
9 – 12 months 
109 

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4.8 
Respiratory rate or mechanical ventilation 
4.8.1 Mean respiratory rate above the 95th 
percentile for age (Table 5)  
OR  
4.8.2 On mechanical ventilation for an acute 
respiratory process not related to underlying 
neuromuscular disease or the receipt of 
general anesthesia.  
 
4.9 
Mechanical ventilation: Invasive and Non-invasive 
ventilation.  
 
Invasive ventilation: Mechanical ventilation 
delivered by positive pressure via endotracheal 
intubation or laryngeal mask use or a tracheostomy.  
 
Non-invasive ventilation: Mechanical ventilation 
delivered by bi-level positive airway pressure 
(BiPAP) through a supra-laryngeal airway by a mask 
or nasopharyngeal tube. Continuous positive airway pressure (CPAP) throughout the 
breathing cycle is not considered Non invasive mechanical ventilation. 
 
4.10 
Infection is defined as: 
4.9.1 A suspected or proven infection caused by any pathogen (by positive culture, 
tissue stain, or polymerase chain reaction test)  
OR  
4.9.2 A clinical syndrome associated with a high probability of infection. Evidence 
of infection includes positive findings on clinical exam, imaging, or laboratory 
tests (i.e. white blood cells in a normally sterile body fluid, perforated viscus, 
chest radiograph consistent with pneumonia, petechial or purpuric rash, or 
purpura fulminans). 
 
 
Table 5: 
95th percentile values for 
respiratory rate in children49 
Age 
Breaths/minute 
0 – 3 months 
60 
3 – 6 months 
57 
6 – 9 months 
55 
9 – 12 months 
52 
12- 18 months 
49 
18 – 24 months 
46 
2 – 3 years 
43 
3 – 4 years 
40 
4 – 6 years 
37 
6 - 8 years 
35 
8 – 12 years 
34 
12 – 15 years 
33 
15 – 18 years 
32 

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6.0 Cardiovascular dysfunction requires the 
presence of one of the 3 following criteria: 
 
6.1 
Decrease in systolic BP (hypotension) <5th 
percentile for age (Table 6). Note that 2 low 
measurements within one hour are required.  
OR 
6.2 
Need for vasoactive drug to maintain BP in 
normal range (dopamine >5 mcg/kg/min or 
any dose of dobutamine, epinephrine, 
norepinephrine, vasopressin/terlipressin, 
phenylephrine or milrinone) 
OR 
6.3 
Two of the following 
6.3.1 Unexplained metabolic acidosis, 
base deficit ≥5.0 mEq/L 
6.3.2 Increased arterial lactate >2 times 
upper limit of normal 
6.3.3 Oliguria: urine output < 1 
mL/kg/hour for 4 hours 
6.3.4 Prolonged capillary refill: > 5 secs 
6.3.5 Core to peripheral temperature gap 
>3°C. Core temperature is measured 
by rectal, bladder, oral or central 
catheter probe. Peripheral 
temperature is measured by 
tympanic, toe, or axillary route. 
 
7.0 
Circulatory overload (also named 
transfusion-associated cardiac overload or TACO) –TACO is a caused de novo by a 
transfusion as a result of fluid overload (positive fluid balance > 20/mL/kg in the last 
day) that appears within 6 hours after the end of a transfusion, with at least one of the 
following criteria: 
7.1 Dyspnea or cyanosis de novo (as reported by nurses). 
7.2 Pulmonary edema de novo. 
7.3 Tachycardia de novo. 
7.4 Hypertension de novo. 
8.0 
Hyperkalemia – Blood level of potassium > 5.5 mmol/L. 
9.0 
Acute Respiratory Distress Syndrome (ARDS)51  
 
PaO2/FiO2 ratio ≤ 300 mmHg 
 
AND 
Confirmation of bilateral opacities (perihilar infiltrates alone are not considered) on chest 
imaging report  
Table 6: 
 <5th percentile for age for systolic BP in 
children50 
Age 
Boys 
Girls 
Systolic BP 
Systolic BP 
0-7 days 
57 
57 
8-30 days 
64 
62 
1-6 months 
72 
72 
6-12 months 
71 
70 
1 yr 
74 
72 
2 yr 
77 
77 
3 yr 
73 
72 
4 yr 
71 
69 
5 yr 
76 
77 
6 yr 
80 
78 
7 yr 
81 
79 
8 yr 
82 
81 
9 yr 
84 
82 
10 yr 
85 
84 
11 yr 
85 
86 
12 yr 
88 
89 
13 yr 
87 
87 
14 yr 
89 
88 
15 yr 
92 
89 
16 yr 
94 
91 
17 yr 
98 
92 

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10.0 
Nosocomial pneumonia –  
A patient with a new or progressive radiographic infiltrate, along with a high clinical 
suspicion of pneumonia plus a definite cause established, must be intubated for at least 48 
hours and diagnosis is made after patient has received a transfusion. 
 
Microbiologically confirmed: The patient must have: 
10.1 
A new or progressive radiographic infiltrate, along with  
10.2 
A high clinical suspicion of pneumonia plus:  
10.3 
A definite cause established by  
10.3.1 Recovery of a probable etiologic agent from an uncontaminated specimen 
(blood, pleural fluid, transtracheal aspirate, or transthoracic aspirate); or 
10.3.2 Recovery from respiratory secretions of a likely pathogen that does not 
colonize the upper airways (e.g., Mycobacterium tuberculosis, Legionella 
species, influenza virus, or Pneumocystis jiroveci (carinii); or 
10.3.3 Recovery of a likely/possible respiratory pathogen in high concentrations 
using quantitative cultures of a lower respiratory tract sample 
(endotracheal aspirate, BAL, or protected specimen brush); or  
10.3.4 Positive serology.  
 
11.0 
Deep vein thrombosis – 
Criteria for clinically suspected or proven deep vein thrombosis will include at least 1 of 
the following symptoms: superficial collateral circulation, jugular swelling, vena cava 
syndrome, edema, pain, inflammation of a limb, fever or signs of a thrombotic 
complication (e.g., pulmonary embolism), as described by Dubois et al. 52 
 
Criteria to identify deep vein thrombosis as diagnosed by ultrasonography will include 
direct visualization of the thrombus, non-compressibility of the vessel, incomplete filling 
of the vein and appearance of respiratory variations on venous flow as described by 
Prandoni et al. 53 
 
Symptomatic and asymptomatic deep vein thromboses will both be reported.  
 
12.0 
Transfusion Associated Graft vs. Host Disease -   
Due to the complexity of this diagnosis, report as present if medical record shows has 
been diagnosed by clinical team within 28 calendar days after the last transfusion. 
13.0 
Hypocalcemia – Defined as an ionized calcium concentration < 0.8 mmol/L (<3.2 
mg.dL) 
14.0 
Delirium- Defined as a CAPD score of >9 following the study transfusion. 
15.0 
Grade 4 SAE- An adverse event, that is life threatening or prolongs the existing 
hospitalization. (Grade 4) 
16.0 
Grade 5 SAE- Death  
 

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9. Appendix 4: Intent to Treat Analysis 
 
Intention To Treat Approach for the ABC-PICU Trial 
 
Purpose: 
Patients can be randomized and not transfused in the ABC-PICU trial due to factors that occur 
prior to randomization and after randomization. Among the patients enrolled up to Oct 1st 2014 
there have been 7/91 patients randomized but not transfused. For 5/7 of these, the patient was not 
transfused because the clinical team decided to not transfuse after randomization. This suggests 
that the clinical team prematurely and inappropriately determined the patient would need a 
transfusion prior to randomization. The other 2 patients were not transfused due to cancellation 
of the surgery in one case and a surgeon’s decision to withdraw their patient from the study in 
the other case. This has prompted us to reevaluate our Intent To Treat approach to be used for 
our primary and secondary analyses in the ABC-PICU trial. It can be appropriate to legitimately 
exclude patients from the Intention To Treat (ITT) approach when the treatment is not received 
after randomization and allocation concealment has not been compromised. Every attempt is 
being made to minimize the number of “non-transfused” occurrences but such occurrences are 
inevitable due to the nature of transfusion trials in acute care settings. 
 
Patients will be excluded from the ITT analysis if the factor that leads to non-transfusion 
occurred before randomization and our masked treatment allocation was not compromised. For 
example, if the surgeon feels a patient will “absolutely” receive a transfusion in the operating 
room before randomization yet eventually no transfusion takes place either during the surgical 
procedure or up to 28 days post-randomization, this patient will be excluded from the ITT 
analysis. For such a patient, the factor leading to non-transfusion was an incorrect assessment 
before randomization by the clinical team.  
 
Process:  
Determination of whether factors leading to non-transfusion according to study protocol were 
present before or after randomization will occur as follows: 
• The basic approach involves inclusion in the ITT analysis of all subjects randomized 
regardless of the timing of transfusion, except if the child is no longer in the ICU when 
transfused. Baseline data will be obtained for all randomized subjects independent of 
whether they are included in the ITT analysis. 
• When a patient is randomized and then not transfused during the 28 days post-
randomization, the local site PI will determine if non-transfusion according to study 
guidelines was due to a factor that occurred before or after randomization.   
• US and Canadian Study Coordinators and Principal Investigators will be accessible to 
assist in this determination.   
• The advice provided to sites to make this determination is the following.  
o If a transfusion was ordered by the clinical team in the ICU or if the surgical team 
determined that the patient would definitively be transfused in the operating room, 
and subsequently no transfusion takes place after randomization, then this is a 
factor that occurred prior to randomization. The requirement for transfusion was 

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incorrectly assessed prior to randomization. Consequently, this patient will be 
excluded from the ITT analysis.   
o If it is deemed that the issue leading to non-transfusion according to study 
guidelines occurred after randomization (for example, a surgeon decides during 
surgery that only fresh blood be administered), then the patient will remain in the 
ITT analysis. 
 
• The diagram below shows the approach that will be used for patients randomized and not 
initially transfused:  
 
 
 

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• The US and Canadian coordinating center will inform the DCC whether the patient is to 
be included or excluded from the ITT analysis and will advise the clinical site of the data 
collection expected. 
 
Data collection:  
 
• All patients randomized and not initially transfused must continue to be monitored up to 28 
days post-randomization. 
 
• For a patient who is randomized and eventually transfused AND who will be included in the 
ITT analysis,  the data collected will depend on whether the first transfusion occurs in ICU or 
after ICU discharge.  
 
 
o If the first transfusion occurs in ICU, baseline data, 28-day study period data, 28-
day mortality and 90-mortality will be collected.  
o If the first transfusion occurs after ICU discharge, baseline data, 28-day mortality 
and 90-day mortality will be collected; 28-day study period data will not be 
collected for these patients because it is not possible to collect all the data 
required to ascertain development of NPMODS outside of an ICU. 
 
• For a patient who is randomized and never transfused during the 28-day study period AND 
who will be included in the ITT analysis, clinical sites will collect baseline data, 28-day 
mortality and 90-day mortality. For patients not transfused following randomization, the 
eCRF allows for the clinical site coordinator to record the following deviations: Patient 
randomized before OR but did not get RBCs, RBC transfusion cancelled, Patient died before 
being transfused, RBC transfusion delayed, Other(s) (specify). 
 
• For a patient who is randomized and never transfused during the 28-day study period and 
who is excluded from the ITT analysis, only baseline data will be collected. 
 
 
 
 
 

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10. Protocol References: 
 
1. 
Zimrin AB, Hess JR. Current issues relating to the transfusion of stored red blood cells. Vox 
Sang 2009;96:93-103. 
2. 
van de Watering L. Red cell storage and prognosis. Vox Sang 2011;100:36-45. 
3. 
Wang D, Sun J, Solomon SB, Klein HG, Natanson C. Transfusion of older stored blood and 
risk of death: a meta-analysis. Transfusion 2012;52:1184-95. 
4. 
Tinmouth A, Fergusson D, Yee IC, Hebert PC. Clinical consequences of red cell storage in 
the critically ill. Transfusion 2006;46:2014-27. 
5. 
Lacroix J, Tucci M. [Clinical impact of length of storage before red blood cell transfusion]. 
Transfus Clin Biol 2011;18:97-105. 
6. 
Hess JR. Red cell changes during storage. Transfus Apher Sci 2010. 
7. 
Kor DJ, Van Buskirk CM, Gajic O. Red blood cell storage lesion. Bosn J Basic Med Sci 
2009;9 Suppl 1:21-7. 
8. 
Tinmouth A, Chin-Yee I. The clinical consequences of the red cell storage lesion. 
Transfusion medicine reviews 2001;15:91-107. 
9. 
Triulzi DJ, Yazer MH. Clinical studies of the effect of blood storage on patient outcomes. 
Transfus Apher Sci 2010;43:95-106. 
10. Vamvakas EC. Meta-analysis of clinical studies of the purported deleterious effects of "old" 
(versus "fresh") red blood cells: are we at equipoise? Transfusion 2010;50:600-10. 
11. Spinella PC, Perkins JG, Grathwohl KW, et al. Risks associated with fresh whole blood and 
red blood cell transfusions in a combat support hospital. Crit Care Med 2007;35:2576-81. 
12. Silliman CC, Moore EE, Johnson JL, Gonzalez RJ, Biffl WL. Transfusion of the injured 
patient: proceed with caution. Shock 2004;21:291-9. 
13. Escobar GA, Cheng AM, Moore EE, et al. Stored packed red blood cell transfusion up-
regulates inflammatory gene expression in circulating leukocytes. Ann Surg 2007;246:129-
34. 
14. Spinella PC, Carroll CL, Staff I, et al. Duration of red blood cell storage is associated with 
increased incidence of deep vein thrombosis and in-hospital mortality in patients with 
traumatic injuries. Crit Care 2009;13:R151. 
15. Arslan E, Sierko E, Waters JH, Siemionow M. Microcirculatory hemodynamics after acute 
blood loss followed by fresh and banked blood transfusion. Am J Surg 2005;190:456-62. 
16. Kirkpatrick UJ, Adams RA, Lardi A, McCollum CN. Rheological properties and function of 
blood cells in stored bank blood and salvaged blood. Br J Haematol 1998;101:364-8. 
17. Biffl WL, Moore EE, Offner PJ, Ciesla DJ, Gonzalez RJ, Silliman CC. Plasma from aged 
stored red blood cells delays neutrophil apoptosis and primes for cytotoxicity: abrogation by 
poststorage washing but not prestorage leukoreduction. J Trauma 2001;50:426-31; 
discussion 32. 
18. Cardo LJ, Hmel P, Wilder D. Stored packed red blood cells contain a procoagulant 
phospholipid reducible by leukodepletion filters and washing. Transfus Apher Sci 
2008;38:141-7. 
19. Cardo LJ, Wilder D, Salata J. Neutrophil priming, caused by cell membranes and 
microvesicles in packed red blood cell units, is abrogated by leukocyte depletion at 
collection. Transfus Apher Sci 2008;38:117-25. 
20. Sweeney J, Kouttab N, Kurtis J. Stored red blood cell supernatant facilitates thrombin 
generation. Transfusion 2009. 

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21. Zallen G, Moore EE, Ciesla DJ, Brown M, Biffl WL, Silliman CC. Stored red blood cells 
selectively activate human neutrophils to release IL-8 and secretory PLA2. Shock 
2000;13:29-33. 
22. Silliman CC, Clay KL, Thurman GW, Johnson CA, Ambruso DR. Partial characterization 
of lipids that develop during the routine storage of blood and prime the neutrophil NADPH 
oxidase. The Journal of laboratory and clinical medicine 1994;124:684-94. 
23. Silliman CC, Ambruso DR, Boshkov LK. Transfusion-related acute lung injury. Blood 
2005;105:2266-73. 
24. Kiraly LN, Underwood S, Differding JA, Schreiber MA. Transfusion of aged packed red 
blood cells results in decreased tissue oxygenation in critically injured trauma patients. J 
Trauma 2009;67:29-32. 
25. Fitzgerald RD, Martin CM, Dietz GE, Doig GS, Potter RF, Sibbald WJ. Transfusing red 
blood cells stored in citrate phosphate dextrose adenine-1 for 28 days fails to improve tissue 
oxygenation in rats. Crit Care Med 1997;25:726-32. 
26. Doctor A, Platt R, Sheram ML, et al. Hemoglobin conformation couples erythrocyte S-
nitrosothiol content to O2 gradients. Proc Natl Acad Sci U S A 2005;102:5709-14. 
27. Bennett-Guerrero E, Veldman TH, Doctor A, et al. Evolution of adverse changes in stored 
RBCs. Proc Natl Acad Sci U S A 2007;104:17063-8. 
28. Raat NJ, Verhoeven AJ, Mik EG, et al. The effect of storage time of human red cells on 
intestinal microcirculatory oxygenation in a rat isovolemic exchange model. Crit Care Med 
2005;33:39-45. 
29. Napolitano LM, Corwin HL. Efficacy of red blood cell transfusion in the critically ill. Crit 
Care Clin 2004;20:255-68. 
30. Reynolds JD, Ahearn GS, Angelo M, Zhang J, Cobb F, Stamler JS. S-nitrosohemoglobin 
deficiency: a mechanism for loss of physiological activity in banked blood. Proceedings of 
the National Academy of Sciences of the United States of America 2007;104:17058-62. 
31. Blajchman MA. Immunomodulation and blood transfusion. Am J Ther 2002;9:389-95. 
32. Landers DF, Hill GE, Wong KC, Fox IJ. Blood transfusion-induced immunomodulation. 
Anesth Analg 1996;82:187-204. 
33. Vamvakas EC, Blajchman MA. Transfusion-related immunomodulation (TRIM): an update. 
Blood Rev 2007;21:327-48. 
34. Waanders M, Van de Watering L, Brand A. Immunomodulation and allogeneic blood 
transfusion. Transfusion Alternatives in Transfusion Medicine 2008;10:127-38. 
35. Sparrow RL. Red blood cell storage and transfusion-related immunomodulation. Blood 
Transfus 2010;8 Suppl 3:s26-30. 
36. Karam O, Tucci M, Toledano BJ, et al. Length of storage and in vitro immunomodulation 
induced by prestorage leukoreduced red blood cells. Transfusion 2009;49:2326-34. 
37. Hill GE, Frawley WH, Griffith KE, Forestner JE, Minei JP. Allogeneic blood transfusion 
increases the risk of postoperative bacterial infection: a meta-analysis. J Trauma 
2003;54:908-14. 
38. Levine J, Kofke A, Cen L, et al. Red blood cell transfusion is associated with infection and 
extracerebral complications after subarachnoid hemorrhage. Neurosurgery 2010;66:312-8; 
discussion 8. 
39. Blumberg N. Deleterious clinical effects of transfusion immunomodulation: proven beyond 
a reasonable doubt. Transfusion 2005;45:33S-9S; discussion 9S-40S. 
40. Morrison AL, Gillis J, O'Connell AJ, Schell DN, Dossetor DR, Mellis C. Quality of life of 
survivors of pediatric intensive care. Pediatr Crit Care Med 2002;3:1-5. 

Study Protocol 
CONFIDENTIAL 
Amendment 2.1 
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41. Silliman CC, Moore EE, Kelher MR, Khan SY, Gellar L, Elzi DJ. Identification of lipids 
that accumulate during the routine storage of prestorage leukoreduced red blood cells and 
cause acute lung injury. Transfusion 2011;51:2549-54. 
42. Bateman ST, Lacroix J, Boven K, et al. Anemia, blood loss, and blood transfusions in North 
American children in the intensive care unit. Am J Respir Crit Care Med 2008;178:26-33. 
43. Karam O, Tucci M, Bateman ST, et al. Association between length of storage of red blood 
cell units and outcome of critically ill children: a prospective observational study. Crit Care 
2010;14:R57. 
44. Gauvin F, Spinella PC, Lacroix J, et al. Association between length of storage of transfused 
red blood cells and multiple organ dysfunction syndrome in pediatric intensive care patients. 
Transfusion 2010;50:1902-13. 
45. Lacroix J, Hebert PC, Hutchison JS, et al. Transfusion strategies for patients in pediatric 
intensive care units. N Engl J Med 2007;356:1609-19. 
46. Proulx F, Fayon M, Farrell CA, Lacroix J, Gauthier M. Epidemiology of sepsis and multiple 
organ dysfunction syndrome in children. Chest 1996;109:1033-7. 
47. Vamvakas E, Pineda AA. Allergic and anaphylactic reactions. In: Popovsky MA, ed. 
Transfusion reactions. 2nd ed. Bethesda, MD: AABB Press; 2001:83-128. 
48. Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: 
definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005;6:2-8. 
49. Fleming S, Thompson M, Stevens R, et al. Normal ranges of heart rate and respiratory rate 
in children from birth to 18 years of age: a systematic review of observational studies. 
Lancet 2011;377:1011-8. 
50. Park MK. Blood pressure. Pediatrics 1987;80:459-61. 
51. Thomas NJ, Shaffer ML, Willson DF, Shih MC, Curley MA. Defining acute lung disease in 
children with the oxygenation saturation index. Pediatr Crit Care Med 2010;11:12-7. 
52. Dubois J, Rypens F, Garel L, David M, Lacroix J, Gauvin F. Incidence of deep vein 
thrombosis related to peripherally inserted central catheters in children and adolescents. 
CMAJ 2007;177:1185-90. 
53. Prandoni P, Polistena P, Bernardi E, et al. Upper-extremity deep vein thrombosis. Risk 
factors, diagnosis, and complications. Arch Intern Med 1997;157:57-62. 
54.  Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. American Psychiatric 
Association; 2013.  
55.  Smith HAB, Boyd J, Fuchs DC, et al. Diagnosing delirium in critically ill children: Validity 
and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit*. 
Crit Care Med. 2011 Jan;39(1):150–7.  
56.  Silver G, Traube C, Gerber LM, et al. Pediatric Delirium and Associated Risk Factors: A 
Single-Center Prospective Observational Study*. Pediatr Crit Care Med. 2015 
May;16(4):303–9.  
57.  Traube C, Mauer EA, Gerber LM, et al. Cost Associated With Pediatric Delirium in the 
ICU: Crit Care Med. 2016 Aug;1.  
58.  Behrends M, DePalma G, Sands L, Leung J. Association Between Intraoperative Blood 
Transfusions and Early Postoperative Delirium in Older Adults. J Am Geriatr Soc. 2013 
Mar;61(3):365–70.  
59.  Zhang Z-Y, Gao D-P, Yang J, et al. Impact of length of red blood cells transfusion on 
postoperative delirium in elderly patients undergoing hip fracture surgery: A cohort study. 
Injury. 2016 Feb;47(2):408–12.  
60.  Harris J, Ramelet A-S, van Dijk M, et al. Clinical recommendations for pain, sedation, 

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withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position 
statement for healthcare professionals. Intensive Care Med. 2016 Jun;42(6):972–86. 
61. Traube C, Silver G, Reeder RW, et al. Pediatric Delirium in Critically-Ill Children: An 
International Point Prevalence Study. Critical Care Medicine. 2016; In press.