Effects of a restrictive blood transfusion protocol on acute pediatric burn care: Transfusion threshold in pediatric burns

VARIABLES INFLUENCING THE DIFFERENTIAL HOST RESPONSE TO BURNS IN PEDIATRIC AND ADULT PATIENTS

ABSTRACT

Burn injury is a significant source of morbidity and mortality in the pediatric population. Although 40,000 pediatric patients in the United States are admitted to the hospital with burn wounds annually, significant differences exist in the management and treatment of these patients, even among highly specialized burn centers. Some aspects of pediatric burn research, such as metabolic changes and nutritional support after burn injury, have been studied extensively; however, in many aspects of burn care, pediatric research lags behind the study of adult populations. This review compares and contrasts a wide array of physiologic and immune responses between children and adults after burn injury. Such a review elucidates where robust research has been conducted, where adult research is applicable to pediatric patients, and where additional pediatric burn research needs to be conducted.

Perioperative Pediatric Erythrocyte Transfusions: Incorporating Hemoglobin Thresholds and Physiologic Parameters in Decision-making

This article presents current literature and scientific evidence on hemoglobin thresholds and physiologic parameters to guide decisions regarding perioperative erythrocyte transfusions in pediatric patients based on the most up-to-date studies and expert consensus recommendations.

Determining transfusion use in major burn patients: A retrospective review and analysis from 2009 to 2019

Blood transfusion is an important treatment for patients with major burns. Understanding the predictive factors of blood product usage in major burns can improve effective transfusion therapy. We retrospectively reviewed the medical records of the Burn Center, First Affiliated Hospital of the Chinese Naval Military Medical University, from August 2009 to July 2019 and enrolled all patients with major burns treated in that decade. Basic information, condition, and blood-transfusion details of the patients were analyzed to identify predictive factors for blood use and prognosis. Despite a yearly decreasing trend, the frequency of use of blood-product usage in major burns was high at 57.72%, with 5.39 times and 28.76 units of blood usage per person. Burn area was the most important predictive factor for blood transfusion at different stages. Burn depth, combined with injury, age, and other factors, affected blood use. Blood use or volume correlated with prognosis; especially, platelet and cryoprecipitate use was significantly associated with increased mortality. Blood product usage in major burns patients is related not only to the clinical condition, but also to doctors' experience, which can predict prognosis. Blood use is associated with increased mortality, although we found no evidence of a causal association.

Coagulation Disorders And Mortality In Burn Injury: A Systematic Review

Even though coagulopathy is a familiar entity in trauma, its relationship to burn injury remains unclear. Literature appears inconsistent as to the conclusions of the use of coagulation assays, either routine methods or newer viscoelastic coagulation assays (VCAs), thromboelastography (TEG) and rotational thromboelastometry (ROTEM), for prediction of patients' coagulation status and mortality. The use of diagnostic assays as mortality markers will be of great importance, since they would recognize at early stages patients with great medical demands and objectify burn injury severity. The aim of this study was to review the literature and evaluate burn patients' characteristics and coagulation markers in the early post burn period. The secondary outcome was to investigate the role of different coagulation assays in mortality prognosis. Literature search was performed using PubMed, ScienceDirect, Wiley Online Library, Google Scholar, Proquest Dissertation and Theses Global, Scopus and Cochrane Library databases. All types of articles referring to adults with any type of burn injury admitted in the first 24h assessing coagulation and mortality were included. PRISMA guidelines ensured the evidence-based process. Eleven studies met the eligibility criteria. This review demonstrated the indubitable relationship of coagulopathy with burn injury and its significant impact on mortality. The rapid and dynamic process of coagulation makes standard coagulation assays unable to detect short-lived haemostatic changes. More susceptible markers such as VCAs need to be applied to the routine assessment of burn patients in order to obtain an overview on coagulopathy and standardize the gained knowledge.

Tranexamic acid reduced blood transfusions in acute burn surgery: A retrospective case-controlled trial

OBJECTIVE

Early excision and grafting of burn wounds are key for reducing prevalence of infection and sepsis. However, it is associated with massive blood loss and patients frequently require large numbers of blood transfusions. This study aimed to evaluate the effect of tranexamic acid (TXA) on blood transfusion requirements in acute burn surgery.

METHODS

Patients admitted to the burn intensive care unit between January 2018 and May 2021 and received TXA before first surgery for wound excision and grafting were matched in a 1:2 ratio to patients that did not receive TXA (confounders age,sex,total body surface area (TBSA) burned). Primary endpoint of the analysis was the total number of transfused units of red blood cells (RBC) intra- and postoperatively up to 48 h. Fresh frozen plasma (FFP) and platelets were evaluated. Endpoints were compared between groups using van Elteren tests adjusting for strata variable age, gender, TBSA.

RESULTS

Twenty-six TXA patients were matched with 52 control patients resulting in similar distributions of gender (77.9%(TXA)vs. 82.7%(control) males, p=0.542), age (51.7±21.3vs.48.3 ±17.4years,p = 0.459) and %TBSA burned (33.5%(IQR34)vs. 38.5% (IQR 30.5),p = 1.000). TXA group received significantly less RBC units intraoperatively (2.5(IQR 2.0)vs.4.0 units (IQR4.0), p = 0.038) and in total (4.0(IQR3.0)vs.6.0(IQR4.0),p = 0.017). TXA patients also received less blood products in general (RBC, FFP, platelets) in each period and in total. We found no significant difference in length of stay (24.0(IQR26.0)vs.33.0 days (IQR 0.5),p = 0.367) or mortality (15.4%vs.21.2%, p = 0.542).

DISCUSSION

This study shows that necessity for blood transfusions in acute burn surgery may be reduced significantly by administration of TXA perioperatively. Randomized-controlled trials are needed to prove these findings.

Intraoperative transfusion practice in burned children in a university hospital over four years: a retrospective analysis

BACKGROUND

Patient blood management programs should be applied to the pediatric population, but little is known about the current transfusion practice of pediatric burn injury patients. This retrospective study was performed to evaluate the practice of red blood cell (RBC) transfusion in children with burn injury, their predictive factors, and adherence to the German transfusion guideline.

METHODS

We reviewed the RBC transfusion practice of all children younger than 8 years with burn injury who were operated during a four-year period in a German university medical center. We analyzed the data associated with transfusion and guideline conformity of transfusion triggers for RBCs from the beginning to the end of hospital stay using logistic regression.

RESULTS

During the four-year period, 138 children (median age 21 months, minimum-maximum 9-101 months) with burn injury needed surgery, 31 children were transfused with RBCs. During their hospital stay, the median hemoglobin concentrations (Hb) of transfused and non-transfused children were 8 g/dL (6.3-11.3 g/dL) and 10.7 (7-13.8 g/dL), respectively. Total body surface area burned (TBSA) (OR = 1.17 per % TBSA, 95% CI = [1.05; 1.30], p = 0.0056), length of surgery (OR = 1.016 per minute, 95% CI = [1.003; 1.028], p = 0.0150), and Hb (OR = 0.48 per 1 g/dl in Hb, 95% CI = [0.24; 0.95], p = 0.0343) were associated with transfusion while other factors (age, gender, ASA, and catecholamines) did not show notable association. Length of stay was mainly influenced by TSBA (+ 1.38 days per %, p <  0.0001), age (+ 0.21 days per month, p = 0.0206), and administering of catecholamines (+ 14.3 days, p = 0.0118), but not by RBC transfusion. The decision to transfuse was in 23% too restrictive and in 74% too liberal according to the German guidelines.

CONCLUSIONS

Amount of TBSA, length of surgery, and Hb influenced the RBC transfusion rate in burned children. However, age and length of stay were not affected by transfusion of RBCs. In clinical practice of burned children, physicians follow a more liberal transfusion strategy than the proposed in guidelines.

The Pediatric Burn: Current Trends and Future Directions

Management of the pediatric burn patient presents a variety of clinical challenges for the pediatric anesthesiologist. Despite the high incidence of burn injuries, standard management strategies are far from universal. The complex physiologic changes presented by burn injuries present airway management and resuscitation challenges and mandate careful consideration of adequate nutritional support. Long hospital stays with frequent operations and dressing changes necessitate creative approaches to anxiolysis and pain control. Underutilized modalities warranting further research include regional anesthesia and nonpharmacologic approaches, such as virtual reality. Further research and collaboration between burn centers are needed to standardize care for this population.

The best strategy for red blood cell transfusion in severe burn patients, restrictive or liberal: A randomized controlled trial

INTRODUCTION

Although blood transfusion is common in burns, data are lacking in appropriate transfusion thresholds. It has been reported that a restrictive blood transfusion policy decreases blood utilization and improves outcomes in critically ill adults, but the impact of a restrictive blood transfusion policy in burn patients is unclear. We decided to investigate the outcome of decreasing the blood transfusion threshold.

MATERIAL AND METHODS

Eighty patients with TBSA > 20% who met our inclusion criteria were included. They were randomly divided into control and intervention groups. The intervention group received packed cells only when Hemoglobin declined to less than 8 g/dL at routine laboratory evaluations. While the control group received packed-cell when hemoglobin was declined to less than 10 g/dl. The total number of the received packed cell before, during and after any surgical procedure was recorded. The outcome was measured by the evaluation of the infection rate and other complications.

RESULT

The mean hemoglobin level before transfusion was 7.7 ± 0.4 g/dL in the restrictive group and 8.8 ± 0.7 g/dL in the liberal group. The mean number of RBC unit transfusion per patient in the restrictive group was significantly lower than the traditional group (3.28 ± 2.2 units vs. 5.9 ± 3.7 units) (p-value = 0.006). The total number of RBC transfused units varied significantly between the two groups (p-value = 0.014). The number of transfused RBC units outside the operation room showed a significant difference between groups (restrictive: 2.8 ± 1.4 units vs. liberal: 4.4 ± 2.6 units) (p = 0.004). We did not find any significant difference in mortality rate or other outcome measures between groups.

CONCLUSION

Applying the restrictive transfusion strategy in thermal burn patients who are highly prone to all kinds of infection, does not adversely impact the patient outcome, and results in significant cost savings to the institution and lower rate of infection. We conclude that the restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications.

CLINICAL TRIAL REGISTRATION REFERENCE

IRCT20190209042660N1.

Pediatric burn resuscitation, management, and recovery for the pediatric anesthesiologist

PURPOSE OF REVIEW

The purpose of this article is to summarize literature in pediatric burn resuscitation and management that is relevant to the pediatric anesthesiologist. The scope of the literature is expanding as long-term survival in even the most critically ill, burn-injured children has increased.

RECENT FINDINGS

Longstanding variations in the care of burn-injured children exist despite decades of experience in burn care management. There seems to be a discomfort outside major burn centers in the triage, evaluation, and assessment of burned children. This is evidenced by the prevalence of 'unnecessary intubations', continued overestimation of total body surface area injured, and subsequent fluid administration disproportionate to injury leading to over-resuscitation. Techniques, such as virtual reality and regional anesthesia are increasingly available and serve adjuncts to pharmacologic therapies for anxiolysis and analgesia. Such techniques reduce opioid utilization while maintaining patient comfort and satisfaction particularly during wound dressing changes. Questions about transfusion threshold and ratio of blood products remain topics of ongoing research.

SUMMARY

Literature review continues to reveal underpowered or retrospective analyses of these very important questions. Public health burden caused by burns warrants rigorous, prospective studies to take the best care of these patients and portend the best long-term outcomes. Collaboration amongst pediatric anesthesiologists who care for these children is necessary to develop and execute powered studies to answer important questions.

Transfusion and Infections in the Burn Patient

Background: Blood product transfusion has historically been utilized after major burn injury in the resuscitative as well as the acute phase. Transfusion has been implicated in infection and immunosuppression in many disease states. Recommendations for blood product transfusion has varied, but several landmark studies have helped define optimal burn transfusion strategies with respect to infection. The purpose of this article is to review the evidence describing the relation between transfusion and infection in burn injury during different phases of burn treatment to identify optimal transfusion strategies and suggest future targets for transfusion research in burns. Methods: This article presents the history, current status, and future research directions related to blood and blood product transfusion in burn injury. Results: Patients with burns are subject to infectious complications resulting from the loss of skin and burn-related immunosuppression. The use of blood in burn treatment has varied during both the resuscitative phase and the acute treatment phase. Whole-blood use in resuscitation was replaced with crystalloid infusion. Future trials are examining the role of plasma and albumin in burn resuscitation. A randomized prospective multicenter transfusion trial was able to decrease transfusion by 50% with no change in infection. Further examination of the role of hemostatic resuscitation in burn excision may help to better define transfusion goals. Conclusions: Blood product transfusion in burn injury has varied throughout the last century. Although advances in the understanding of blood transfusion in burn injury have occurred, initiatives to define optimal care better are required.

Red cell use in trauma

PURPOSE OF REVIEW

Red cell transfusions are commonly used in management of hemorrhage in trauma patients. The appropriate indications and criteria for transfusion are still debated. Here, we summarize the recent findings on the use of red cell transfusion in trauma setting.

RECENT FINDINGS

Recent evidence continues to support the long-established link between allogeneic transfusion and worse clinical outcomes, reinstating the importance of more judicious use of allogeneic blood and careful consideration of benefits versus risks when making transfusion decisions. Studies support restrictive transfusion strategies (often based on hemoglobin thresholds of 7-8 g/dl) in most patient populations, although some argue more caution in specific populations (e.g. patients with traumatic brain injury) and more studies are needed to determine if these patients benefit from less restrictive transfusion strategies. It should be remembered that anemia remains an independent risk factor for worse outcomes and red cell transfusion does not constitute a lasting treatment. Anemia should be properly assessed and managed based on the cause and using hematinic medications as indicated.

SUMMARY

Although the debate on hemoglobin thresholds for transfusion continues, clinicians should not overlook proper management of the underlying issue (anemia).

Burn injury and blood transfusion

PURPOSE OF REVIEW

Blood transfusion is ubiquitous in major burn injury. The present article describes recent research findings directly impacting blood transfusion strategies in major burn injury both in the operating room and the ICU.

RECENT FINDINGS

Transfusion strategies have been the focus of recent burn investigations. First, a randomized prospective trial encompassing both the ICU and operating room reported that a restrictive red blood cell transfusion threshold (7 g/dl) had equivalent outcomes to a traditional threshold (10 g/dl) for burns more than 20% in terms of mortality, infection, length of stay, duration of mechanical ventilation, and wound healing despite receiving significantly fewer transfusions. The second burn transfusion advance addresses coagulation. Although burn patients initially have elevated fibrinogen, thrombocytopenia and other coagulation disorders develop during excision. Blood product repletion should be based on measurements such as thromboelastography in addition to traditional tests. Finally, a recent randomized trial suggests that fresh-frozen plasma and platelets during burn excision more than 20% may decrease transfusion requirements.

SUMMARY

A restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications. Repletion of coagulation products should focus on measured deficits of platelets, fibrinogen, and factors.