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Adkins BD, Noland DK, Jacobs JW, Booth GS, Malicki D, Helander L, Jacquot C, Buscema G, Goel R, Andrews J, Lieberman L. Survey of pediatric massive transfusion protocol practice at United States level I trauma centers: An AABB Pediatric Transfusion Medicine Subsection study. Transfusion 2024. [PMID: 39245887 DOI: 10.1111/trf.17997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 06/28/2024] [Accepted: 08/11/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND Trauma remains the leading cause of pediatric mortality in the United States. Although use of massive transfusion protocols (MTPs) in this population is widespread, optimal pediatric resuscitation is not well established. We sought to assess contemporary pediatric MTP practice in the United States. STUDY DESIGN AND METHODS A web-based survey was designed by the Association for the Advancement of Blood & Biotherapies (AABB) Pediatric Transfusion Medicine Subsection and distributed to select American College of Surgeons (ACS) Level I Verified pediatric trauma centers. The survey assessed current MTP policy, implementation, and recent changes in practice. RESULTS Response rate was 55% (22/40). Almost half of the respondents were from the South. The median RBC:plasma ratio was 1 (interquartile range 1-1.5). Protocolized fibrinogen supplementation was common while integration of antifibrinolytic therapy into MTPs was infrequent. Viscoelastic testing (VET) was available at most sites, 71% (15/21, one site did not respond), and was generally utilized on an ad-hoc basis. Roughly, a third of sites had changed their MTP in the past 3 years due to blood supply issues, and about a third reported having group O Whole Blood on-site. CONCLUSION MTP practice is similar throughout the United States. Though fibrinogen supplementation is common-other emerging interventions such as antifibrinolytic therapy or utilization of routine viscoelastic testing-are not widespread. Pediatric transfusion medicine experts must continue to follow practice change, as contemporary large trials begin to characterize new supportive modalities to optimize resuscitation in pediatric trauma patients.
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Affiliation(s)
- Brian D Adkins
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Children's Health System, Dallas, Texas, USA
| | - Daniel K Noland
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Children's Health System, Dallas, Texas, USA
| | - Jeremy W Jacobs
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Garrett S Booth
- Department of Pathology, Microbiology, & Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Denise Malicki
- Department of Pathology, Rady Children's Hospital San Diego, San Diego, California, USA
| | - Louise Helander
- Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Cyril Jacquot
- Department of Pathology, Children's National Hospital, Washington, DC, USA
| | - Gina Buscema
- Transfusion Services, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Ruchika Goel
- Department of Internal Medicine, Simmons Cancer Institute, Southern Illinois University School of Medicine, Springfield, Illinois, USA
- Corporate Medical Affairs, Vitalant, Scottsdale, Arizona, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer Andrews
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lani Lieberman
- Laboratory Medicine Program, University Health Network, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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2
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Al-Riyami AZ, Hejres S, Elshafy SA, Al Humaidan H, Samaha H. Management of massive haemorrhage in transfusion medicine services in the Middle East and North Africa. Vox Sang 2024. [PMID: 39031656 DOI: 10.1111/vox.13701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND AND OBJECTIVES Massive transfusion protocols (MTPs) are critical in managing haemorrhage, yet their utilization varies. There is lack of data on the utilization of MTPs in the Middle East and North Africa (MENA) region. This study aims to assess the degree of utilization of MTPs in the region. MATERIALS AND METHODS We conducted a survey to collect data on MTP use, inviting medical directors of transfusion services from various hospitals. Data were analysed to determine the prevalence of MTP utilization, their compositions, challenges in application and areas of future need. RESULTS Eighteen respondents participated, representing 11 countries in the region. Thirteen hospitals implemented MTP, and eight included paediatrics. Eleven institutions used more than one definition of massive haemorrhage, with the most common being ≥10 red blood cell (RBC) units transfused for adults and replacement of >50% total blood volume in paediatrics. The majority of sites with MTPs utilized 1:1:1 RBCs:platelets:plasma ratio (70%). Variations were observed in the types and blood groups of components used. Two sites utilized whole blood, while six are considering it for future use. Utilization of adjunctive agents and frequency of laboratory testing varied among the sites. Challenges included the lack of medical expertise in protocol development, adherence and paediatric application. The need assessment emphasized the need for developing regional guidelines, standardized protocols and training initiatives. CONCLUSION Although several hospitals have adopted MTPs, variations exist in activation criteria, blood product ratios and monitoring. Challenges include the lack of medical expertise, protocol adherence and addressing paediatric needs. Standardizing protocols, enhancing training and paediatric application are crucial for improving massive transfusion management in the region.
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Affiliation(s)
- Arwa Z Al-Riyami
- Sultan Qaboos University Hospital, University Medical City, Muscat, Oman
| | - Suha Hejres
- Department of Pathology, Blood Bank and Laboratory Medicine, King Hamad University Hospital, Al Sayh, Bahrain
| | - Sanaa Abd Elshafy
- Department of Clinical Pathology, Faculty of Medicine, Beni Sueif University, Beni Suef, Egypt
| | - Hind Al Humaidan
- Blood Bank and Transfusion Medicine, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Hanady Samaha
- Saint George Hospital UMC, Saint George University of Beirut, Beirut, Lebanon
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3
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Arsenault V, Lieberman L, Akbari P, Murto K. Canadian tertiary care pediatric massive hemorrhage protocols: a survey and comprehensive national review. Can J Anaesth 2024; 71:453-464. [PMID: 38057534 DOI: 10.1007/s12630-023-02641-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/27/2023] [Accepted: 07/09/2023] [Indexed: 12/08/2023] Open
Abstract
PURPOSE Hemorrhage is the leading cause of pediatric death in trauma and cardiac arrest during surgery. Adult studies report improved patient outcomes using massive hemorrhage protocols (MHPs). Little is known about pediatric MHP adoption in Canada. METHODS After waived research ethics approval, we conducted a survey of Canadian pediatric tertiary care hospitals to study MHP activations. Transfusion medicine directors provided hospital/patient demographic and MHP activation data. The authors extracted pediatric-specific MHP data from requested policy/procedure documents according to seven predefined MHP domains based on the literature. We also surveyed educational and audit tools. The analysis only included MHPs with pediatric-specific content. RESULTS The survey included 18 sites (100% response rate). Only 13/18 hospitals had pediatric-specific MHP content: eight were dedicated pediatric hospitals, two were combined pediatric/obstetrical hospitals, and three were combined pediatric/adult hospitals. Trauma was the most common indication for MHP activation (54%), typically based on a specific blood volume anticipated/transfused over time (10/13 sites). Transport container content was variable. Plasma and platelets were usually not in the first container. There was little emphasis on balanced plasma/platelet to red-blood-cell ratios, and most sites (12/13) rapidly incorporated laboratory-guided goal-directed transfusion. Transfusion thresholds were consistent with recent guidelines. All protocols used tranexamic acid and eight sites used an audit tool. DISCUSSION/CONCLUSION Pediatric MHP content was highly variable. Activation demographics suggest underuse in nontrauma settings. Our findings highlight the need for a consensus definition for pediatric massive hemorrhage, a validated pediatric MHP activation tool, and prospective assessment of blood component ratios. A national pediatric MHP activation repository would allow for quality improvement metrics.
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Affiliation(s)
- Valérie Arsenault
- Division of Transfusion Medicine, Department of Laboratory Medicine, University of Montreal, Montreal, QC, Canada
- Centre Hospitalier Universitaire (CHU) Sainte-Justine, Mother and Child Hospital of Montreal, Montreal, QC, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Pegah Akbari
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Kimmo Murto
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada.
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd., Ottawa, ON, K1H 8L1, Canada.
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4
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Vlatten A. Pediatric massive hemorrhage-are we all following similar protocols? Can J Anaesth 2024; 71:443-446. [PMID: 38057533 DOI: 10.1007/s12630-023-02640-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 12/08/2023] Open
Affiliation(s)
- Arnim Vlatten
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada.
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5
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Georgette N, Lipton G, Li J. Balanced resuscitation: application to the paediatric trauma population. Curr Opin Pediatr 2023; 35:303-308. [PMID: 36762640 DOI: 10.1097/mop.0000000000001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW Trauma is the leading cause of death in children over 5 years old. Early mortality is associated with trauma-induced coagulopathy (TIC), with balanced resuscitation potentially mitigating the effects of TIC. We review TIC, balanced resuscitation and the best evidence for crystalloid fluid versus early blood products, massive transfusion protocol (MTP) and the optimal ratio for blood products. RECENT FINDINGS Crystalloid fluids have been associated with adverse events in paediatric trauma patients. However, the best way to implement early blood products remains unclear; MTP has only shown improved time to blood products without clear clinical improvement. The indications to start blood products are also currently under investigation with several scoring systems and clinical indications being studied. Current studies on the blood product ratio suggest a 1 : 1 ratio for plasma:pRBC is likely ideal, but prospective studies are needed to further support its use. SUMMARY Balanced resuscitation strategies of minimal crystalloid use and early administration of blood products are associated with improved morbidity in paediatric trauma patients but unclear mortality benefit. Current evidence suggests that the utilization of MTPs with 1 : 1 plasma:pRBC ratio may improve morbidity, but more research is needed.
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Affiliation(s)
- Nathan Georgette
- Boston Children's Hospital, Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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6
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Horst JA, Spinella PC, Leonard JC, Josephson CD, Leeper CM. Cryoprecipitate for the treatment of life-threatening hemorrhage in children. Transfusion 2023; 63 Suppl 3:S10-S17. [PMID: 37070338 PMCID: PMC10364587 DOI: 10.1111/trf.17340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/16/2023] [Accepted: 01/16/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Hypofibrinogenemia is an important risk factor for poor outcomes in children with severe bleeding. There is a paucity of data on the impact of cryoprecipitate transfusion on outcomes in pediatric patients with life-threatening hemorrhage (LTH). STUDY DESIGN AND METHODS This secondary analysis of a multicenter prospective observational study of children with LTH investigated subjects who were categorized by receipt of cryoprecipitate during their resuscitation and according to the etiology of their bleeding: trauma, operative, and medical. Bivariate analysis was performed to identify variables associated with 6-h, 24-h, and 28-day mortality. Cox Hazard regression models were generated to adjust for potential confounders. RESULTS Cryoprecipitate was transfused to 33.9% (152/449) of children during LTH. The median (Interquartile range) time to cryoprecipitate administration was 108 (47-212) minutes. Children in the cryoprecipitate group were younger, more often female, with higher BMI and pre-LTH PRISM score and lower platelet counts. After adjusting for PRISM score, bleeding etiology, age, sex, RBC volume, platelet volume, antifibrinolytic use and cardiac arrest, cryoprecipitate administration was independently associated with lower 6-h mortality, Hazard Ratio (95% CI), 0.41 (0.19-0.89), (p = 0.02) and 24-h mortality, Hazard Ratio (95% CI), 0.46 (0.24-0.89), (p = 0.02). CONCLUSION Cryoprecipitate transfusion to children with LTH was associated with reduced early mortality. A prospective randomized trial is needed to determine if cryoprecipitate can improve outcomes in children with LTH.
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Affiliation(s)
- Jennifer A Horst
- Department of Pediatrics, Washington University, St. Louis, Missouri, USA
| | - Philip C Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Julie C Leonard
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Cassandra D Josephson
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- The Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Christine M Leeper
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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7
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The Use of Blood in Pediatric Trauma Resuscitation. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00356-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
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8
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Borgman MA, Nishijima DK. Tranexamic acid in pediatric hemorrhagic trauma. J Trauma Acute Care Surg 2023; 94:S36-S40. [PMID: 36044459 DOI: 10.1097/ta.0000000000003775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT There is strong evidence in adult literature that tranexamic acid (TXA) given within 3 hours from injury is associated with improved outcomes. The evidence for TXA use in injured children is limited to retrospective studies and one prospective observational trial. Two studies in combat settings and one prospective civilian US study have found association with improved mortality. These studies indicate the need for a randomized controlled trial to evaluate the efficacy of TXA in injured children and to clarify appropriate timing, dose and patient selection. Additional research is also necessary to evaluate trauma-induced coagulopathy in children. Recent studies have identified three distinct fibrinolytic phenotypes following trauma (hyperfibrinolysis, physiologic fibrinolysis, and fibrinolytic shutdown), which can be identified with viscohemostatic assays. Whether viscohemostatic assays can appropriately identify children who may benefit or be harmed by TXA is also unknown.
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Affiliation(s)
- Matthew A Borgman
- From the Brooke Army Medical Center (M.A.B.), Uniformed Services University, Ft. Sam Houston, Texas; and UC Davis Medical Center (D.K.N.), University of California, Sacramento, California
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9
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Russell RT, Bembea MM, Borgman MA, Burd RS, Gaines BA, Jafri M, Josephson CD, Leeper CM, Leonard JC, Muszynski JA, Nicol KK, Nishijima DK, Stricker PA, Vogel AM, Wong TE, Spinella PC. Pediatric traumatic hemorrhagic shock consensus conference research priorities. J Trauma Acute Care Surg 2023; 94:S11-S18. [PMID: 36203242 PMCID: PMC9805504 DOI: 10.1097/ta.0000000000003802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Traumatic injury is the leading cause of death in children and adolescents. Hemorrhagic shock remains a common and preventable cause of death in the pediatric trauma patients. A paucity of high-quality evidence is available to guide specific aspects of hemorrhage control in this population. We sought to identify high-priority research topics for the care of pediatric trauma patients in hemorrhagic shock. METHODS A panel of 16 consensus multidisciplinary committee members from the Pediatric Traumatic Hemorrhagic Shock Consensus Conference developed research priorities for addressing knowledge gaps in the care of injured children and adolescents in hemorrhagic shock. These ideas were informed by a systematic review of topics in this area and a discussion of these areas in the consensus conference. Research priorities were synthesized along themes and prioritized by anonymous voting. RESULTS Eleven research priorities that warrant additional investigation were identified by the consensus committee. Areas of proposed study included well-designed clinical trials and evaluations, including increasing the speed and accuracy of identifying and treating hemorrhagic shock, defining the role of whole blood and tranexamic acid use, and assessment of the utility and appropriate use of viscoelastic techniques during early resuscitation. The committee recommended the need to standardize essential definitions, data elements, and data collection to facilitate research in this area. CONCLUSION Research gaps remain in many areas related to the care of hemorrhagic shock after pediatric injury. Addressing these gaps is needed to develop improved evidence-based recommendations for the care of pediatric trauma patients in hemorrhagic shock.
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Affiliation(s)
- Robert T. Russell
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children’s of Alabama, Birmingham, AL
| | - Melania M. Bembea
- Division of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew A. Borgman
- Department of Pediatrics, Brooke Army Medical Center, Uniformed Services University
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Barbara A. Gaines
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC Children’s Hospital, Pittsburgh, PA
| | - Mubeen Jafri
- Division of Pediatric Surgery, Doernbecher Children’s Hospital, Oregon Health and Science University, Portland, OR
| | - Cassandra D. Josephson
- Department of Oncology, Sydney Kimmel Cancer Center, Johns Hopkins University School of Medicine, Baltimore MD, and Cancer and Blood Disorders Institute, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Christine M. Leeper
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Julie C. Leonard
- Department of Pediatrics, Division of Emergency Medicine, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Jennifer A. Muszynski
- Division of Critical Care Medicine, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Kathleen K. Nicol
- Department of Pathology and Laboratory Medicine, The Ohio State University College of Medicine Nationwide Children’s Hospital, Columbus, OH
| | - Daniel K. Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Paul A. Stricker
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Adam M. Vogel
- Divisions of Pediatric Surgery and Critical Care, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | - Trisha E. Wong
- Division of Pediatric Hematology and Oncology and Department of Pathology, Oregon Health and Science University, Portland, OR
| | - Philip C. Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center. Pittsburgh, PA
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10
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Recognizing life-threatening bleeding in pediatric trauma: A standard for when to activate massive transfusion protocol. J Trauma Acute Care Surg 2023; 94:101-106. [PMID: 36121215 DOI: 10.1097/ta.0000000000003784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Traumatic hemorrhage is the most common cause of preventable death in civilian and military trauma. Early identification of pediatric life-threatening hemorrhage is challenging. There is no accepted clinical critical administration threshold (CAT) in children for activating massive transfusion protocols. METHODS Children 0 to 17 years old who received any transfusion in the first 24 hours after injury between 2010 and 2019 were included. The type, volume, and time of administration for each product were recorded. The greatest volume of weight-adjusted products transfused within 1 hour was calculated. The cut point for the number of products that maximized sensitivity and specificity to predict in-hospital mortality, need for urgent surgery, and second life-threatening bleeding episode was determined using Youden's index. A binary variable (CAT+) was generated using this threshold for inclusion in a multivariable logistic regression model. RESULTS In total, 287 patients were included. The median (interquartile range) age was 6 (2-14) years, 60% were males, 83% sustained blunt trauma, and the median (interquartile range) Injury Severity Score was 26 (17-35). The optimal cutoff to define CAT+ was >20 mL/kg of product; this optimized test characteristics for mortality (sensitivity, 70%; specificity, 77%), need for urgent hemorrhage control procedure (sensitivity, 65%; specificity, 74%). and second bleeding episode (sensitivity, 77%; specificity, 74%). There were 93 children (32%) who were CAT+. On multivariate regression, being CAT+ was associated with 3.4 increased odds of mortality (95% confidence interval, 1.67-6.89; p = 0.001) after controlling for age, hypotension, Injury Severity Score, and Glasgow Coma Scale. For every unit of product administered, there was a 10% increased risk of mortality (odds ratio, 1.1; p < 0.001). CONCLUSION Transfusion of more than 20 mL/kg of any blood product within an hour should be used as a threshold for activating massive transfusion protocols in children. Children who meet this CAT are at high risk of mortality and need for interventions; this population may benefit from targeted, timely, and aggressive hemostatic resuscitation. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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11
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Reppucci ML, Stevens J, Moulton SL, Acker SN. The Recognition of Shock in Pediatric Trauma Patients. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00239-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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12
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Morgan KM, Gaines BA, Leeper CM. Pediatric Trauma Resuscitation Practices. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00238-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Taylor A, Foster NW, Ricca RL, Choi PM. Pediatric Surgical Care During Humanitarian and Disaster Relief Missions. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00237-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Phillips R, Shahi N, Acker SN, Meier M, Shirek G, Stevens J, Recicar J, Moulton S, Bensard D. Not as simple as ABC: Tools to trigger massive transfusion in pediatric trauma. J Trauma Acute Care Surg 2022; 92:422-427. [PMID: 34538826 DOI: 10.1097/ta.0000000000003412] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early and accurate identification of pediatric trauma patients who will receive massive transfusion (MT) is not well established. We developed the ABCD (defined as penetrating mechanism, positive focused assessment with sonography for trauma, shock index, pediatric age-adjusted [SIPA], lactate, and base deficit [BD]) and BIS scores (defined as a combination of BD, international normalized ratio [INR], and SIPA) and hypothesized that the BIS score would perform best in the ability to predict the need for MT in children. METHODS Pediatric trauma patients (≤18 years old) admitted to our trauma center between 2008 and 2019 were identified. Using a receiver operator curve, we defined cutoff points for lactate (≥3.2), BD (≤-6.9), and INR (≥1.4). ABCD scores were calculated by combining penetrating mechanism; positive focused assessment with sonography for trauma examination; SIPA; lactate; and BD. BIS scores were calculated by combining BD, INR, and SIPA. The sensitivity, specificity, and accuracy of each score were calculated based on receiving MT. RESULTS Seven hundred seventy-two patients were included, of which 59 (7.6%) underwent MT. The best predictor of receiving MT was achieved by a BIS score of ≥2 that was 98% sensitive and 23% specific with an area under the curve of 0.81. The ABCD score of ≥2 was 97% sensitive and 20% specific with an area under the curve of 0.77. CONCLUSION The BIS score, which takes into account derangements in acidosis, coagulopathy, and SIPA, is accurate and easy to perform and can be incorporated into a simple bedside screening tool for triggering MT in pediatric trauma patients. LEVEL OF EVIDENCE Diagnostic Tests or Criteria, Level IV.
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Affiliation(s)
- Ryan Phillips
- From the Division of Pediatric Surgery (R.P., N.S., S.N.A., G.S., J.S., J.R., S.M., D.B.), Children's Hospital Colorado; Department of Surgery (R.P., N.S., S.N.A., G.S., J.S., S.M., D.B.) and Center for Research in Outcomes for Children's Surgery (M.M.), Center for Children's Surgery, University of Colorado School of Medicine; Division of Nursing (J.R.), Children's Hospital Colorado, Aurora; and Department of Surgery (D.B.), Denver Health Medical Center, Denver, Colorado
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15
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Reppucci ML, Pickett K, Stevens J, Phillips R, Recicar J, Annen K, Moulton SL. Massive transfusion in pediatric trauma-does more blood predict mortality? J Pediatr Surg 2022; 57:308-313. [PMID: 34736771 DOI: 10.1016/j.jpedsurg.2021.09.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Treatment of severe hemorrhage focuses on the control of bleeding and intravascular volume expansion through massive transfusion (MT). This study aimed to determine if transfusion volumes in pediatric trauma patients who receive MT is associated with increased risk of death, and to establish if there is a threshold above which further resuscitation with blood products is futile. METHODS Pediatric patients (2-18 years old) in the 2014-2017 Trauma Quality Improvement Program (TQIP) database with complete age and blood transfusion data who met the MT definition of 40 mL/kg/24 h were included in analysis. Data elements were cleaned to eliminate discrepancies in reporting blood volumes and erroneous values were excluded. Early mortality was defined as death within 24 h. Late mortality was defined as death more than 24 h after hospital admission. Area under the curve (AUC) was calculated from receiver operating characteristic (ROC) curve analyses to determine upper volume thresholds to predict early versus late mortality. RESULTS There were 633 patients who met the MT definition of 40 mL/kg/24 h. The overall mortality rate was 21.6%. Volume of blood had poor predicting early and late mortality with an AUC of 0.50 [95% CI (0.42, 0.59)] and 0.50 [95% CI (0.43,0.57)], respectively. Regardless of mechanism, no transfusion volume was associated with a predictably high rate of mortality. CONCLUSIONS There is no upper transfusion volume threshold to predict mortality in pediatric trauma patients who are massively transfused, regardless of mechanism. Severely injured children can tolerate massive amounts of blood products and still survive. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Marina L Reppucci
- Division of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Kaci Pickett
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jenny Stevens
- Division of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - John Recicar
- Division of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Division of Nursing, Children's Hospital Colorado, Aurora, CO, USA
| | - Kyle Annen
- Department of Pathology, Children's Hospital of Colorado, Aurora, CO, USA
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Stevens J, Reppucci ML, Meier M, Phillips R, Shahi N, Shirek G, Acker S, Bensard D, Moulton S. Pre-hospital and emergency department shock index pediatric age-adjusted (SIPA) "cut points" to identify pediatric trauma patients at risk for massive transfusion and/or mortality. J Pediatr Surg 2022; 57:302-307. [PMID: 34753559 DOI: 10.1016/j.jpedsurg.2021.09.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 09/27/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Shock index pediatric age-adjusted (SIPA) is a validated measure to identify severely injured children. Previous literature categorized SIPA as normal or elevated, but the relationship between specific SIPA values and outcomes has not been determined. We sought to determine specific SIPA cut points in the pre-hospital and Emergency Department (ED) settings to identify patients at risk for massive transfusion (MT) and/or mortality. METHODS Patients ≤ 18 years old admitted to our Level I pediatric trauma center following trauma activation were included. Youdin J index was used to define pre-hospital and ED SIPA cut points to identify those at risk of MT and/or mortality for the following age groups: < 1 year, 1-6 years, 7-12 years, and > 12 years old. Sensitivity, specificity, accuracy, and area under the curve (AUC) were calculated to determine SIPA threshold values associated with MT and/or mortality. RESULTS Of 1,072 patients, 6.3% (n = 68) required MT and 8.4% (n = 90) died. For predicting MT, pre-hospital SIPA cut points performed best in the > 12 year-old age group (AUC = 0.86) and ED SIPA cut points performed best in the 6-12 year-old age group (AUC = 0.87). For predicting mortality, pre-hospital (AUC = 0.78) and ED SIPA cut points (AUC = 0.84) performed best in the > 12 year-old age group. CONCLUSION Pre-hospital and ED SIPA cut points performed better at predicting MT and/or mortality in older pediatric patients compared to very young children. Age remains an important factor when determining the validity of SIPA to predict outcomes in pediatric trauma patients. STUDY TYPE/LEVEL OF EVIDENCE Level III, Retrospective Cohort Study.
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Affiliation(s)
- Jenny Stevens
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Marina L Reppucci
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Shannon Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Ramos-Jimenez RG, Leeper C. Hemostatic Resuscitation in Children. Transfus Med Rev 2021; 35:113-117. [PMID: 34716083 DOI: 10.1016/j.tmrv.2021.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 02/02/2023]
Abstract
Trauma is a major source of morbidity and mortality for children worldwide; life-threatening hemorrhage is a primary cause of preventable death. Essential interventions in children with life-threatening hemorrhage include hemostatic resuscitation and mechanical control of bleeding. Herein we review pediatric hemostatic resuscitation, a strategy that addresses both hemorrhagic shock and the coagulopathic complications described in patients with major hemorrhage. Some components of hemostatic resuscitation may include: early and aggressive resuscitation with blood products, minimizing crystalloid and hemodilution, antifibrinolytic adjuncts such as tranexamic acid, and the novel use of low-titer group O whole-blood (LTOWB) transfusion in injured children. The following selection of important publications address the current state of hemostatic resuscitation strategies in pediatric trauma patients as well as the remaining knowledge gaps and areas for further research.
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Affiliation(s)
| | - Christine Leeper
- Department of Surgery, UPMC Presbyterian Shadyside, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Abstract
OBJECTIVES The purpose of our study was to describe children with life-threatening bleeding. DESIGN We conducted a prospective observational study of children with life-threatening bleeding events. SETTING Twenty-four childrens hospitals in the United States, Canada, and Italy participated. SUBJECTS Children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under massive transfusion protocol were included. INTERVENTIONS Children were compared according bleeding etiology: trauma, operative, or medical. MEASUREMENTS AND MAIN RESULTS Patient characteristics, therapies administered, and clinical outcomes were analyzed. Among 449 enrolled children, 55.0% were male, and the median age was 7.3 years. Bleeding etiology was 46.1% trauma, 34.1% operative, and 19.8% medical. Prior to the life-threatening bleeding event, most had age-adjusted hypotension (61.2%), and 25% were hypothermic. Children with medical bleeding had higher median Pediatric Risk of Mortality scores (18) compared with children with trauma (11) and operative bleeding (12). Median Glasgow Coma Scale scores were lower for children with trauma (3) compared with operative (14) or medical bleeding (10.5). Median time from bleeding onset to first transfusion was 8 minutes for RBCs, 34 minutes for plasma, and 42 minutes for platelets. Postevent acute respiratory distress syndrome (20.3%) and acute kidney injury (18.5%) were common. Twenty-eight-day mortality was 37.5% and higher among children with medical bleeding (65.2%) compared with trauma (36.1%) and operative (23.8%). There were 82 hemorrhage deaths; 65.8% occurred by 6 hours and 86.5% by 24 hours. CONCLUSIONS Patient characteristics and outcomes among children with life-threatening bleeding varied by cause of bleeding. Mortality was high, and death from hemorrhage in this population occurred rapidly.
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Long E, Williams A, Babl FE, Kinmonth A, Tse WC, Palmer CS, Crighton G, Savoia H, Teague WJ, Nystrup KB. Changes in emergency department blood product use for major paediatric trauma following the implementation of a major haemorrhage protocol. Emerg Med Australas 2021; 33:966-974. [PMID: 33811442 DOI: 10.1111/1742-6723.13773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/05/2021] [Accepted: 03/12/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Fixed ratio blood product administration may improve outcomes in trauma patients with massive blood loss. The present study aimed to describe the impact of a major haemorrhage protocol (MHP) on the ratio of blood products administered for paediatric major trauma. METHODS Retrospective observational study in a state-designated paediatric major trauma centre in Melbourne, Australia. Children with major trauma who received blood products in the ED were identified from a hospital trauma registry. Blood product ratios before, during and after implementation of a hospital MHP were compared in consecutive 2 year blocks. RESULTS Over a 6 year period, 767 major trauma patients were identified, of whom 47 received blood products in the ED and were included in the analysis; 14 pre-MHP implementation, 24 during-MHP implementation and nine post-MHP implementation. No patients received blood products at a ratio of 1:1:1 for red blood cells:fresh frozen plasma:platelets, respectively, during any time period. In this cohort of predominantly blunt trauma, blood products were infrequently administered in the ED because of the low prevalence of massive blood loss. Coagulopathy and hypofibrinogenaemia were commonly observed, nearly half of included patients were managed operatively and one quarter did not survive their injuries. CONCLUSION The implementation of a MHP did not change the ratio of blood product administration in this cohort of patients because of the infrequency of massive blood loss. Future studies may focus on the impact of treating coagulopathy and hypofibrinogenaemia on patient-centred outcomes.
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Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Department of Medicine and Radiology, Melbourne Medical School, Melbourne, Victoria, Australia
| | - Amanda Williams
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Department of Medicine and Radiology, Melbourne Medical School, Melbourne, Victoria, Australia
| | - Anne Kinmonth
- Department of Haematology, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Wai Chung Tse
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Cameron S Palmer
- Trauma Service, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Gemma Crighton
- Department of Haematology, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Helen Savoia
- Department of Haematology, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Warwick J Teague
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Trauma Service, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Kristin Brønnum Nystrup
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
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Neff LP, Beckwith MA, Russell RT, Cannon JW, Spinella PC. Massive Transfusion in Pediatric Patients. Clin Lab Med 2020; 41:35-49. [PMID: 33494884 DOI: 10.1016/j.cll.2020.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Massive transfusion in pediatric patients is infrequent but associated with much higher mortality than in adults. Blood transfusion and hematology has conceptualized ideas such as blood failure and the interplay of the blood-endothelium interface to understand coagulopathy in the context of hemorrhagic shock. Researchers are still searching for an appropriate definition of what constitutes a pediatric massive transfusion. There is no universally accepted protocol for massive transfusion and how to address the many complications that can arise. Pharmacologic adjuncts to resuscitation may prove beneficial in reducing coagulopathy during pediatric massive transfusion, but high-quality evidence has not yet emerged.
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Affiliation(s)
- Lucas P Neff
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest University School of Medicine, 5th Floor, Watlington Hall, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
| | - Michael Aaron Beckwith
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 1922 7th Avenue South, KB 120, Birmingham, AL 35294, USA
| | - Robert T Russell
- Pediatric General Surgery, Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, 1600 7th Avenue South, Lowder, Suite 300, Birmingham, AL 35233, USA
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Penn Presbyterian Medical Center, 51 North 39th Street, Suite 120 MOB, Philadelphia, PA 19104, USA
| | - Philip C Spinella
- Division of Critical Care Medicine, Department of Pediatrics, The Washington University of Saint Louis, 4905 Children's Place, St Louis, MO 63110, USA
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21
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Comparing unbalanced and balanced ratios of blood products in massive transfusion to pediatric trauma patients: effects on mortality and outcomes. Eur J Trauma Emerg Surg 2020; 48:179-186. [PMID: 32797258 PMCID: PMC7426595 DOI: 10.1007/s00068-020-01461-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 08/05/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND The utilization and impact of various ratios of transfusions for pediatric trauma patients (PTPs) receiving a massive transfusion (MT) are unknown. Therefore, we sought to determine the risk for mortality in PTPs receiving an MT of ≥ 6 units of packed red blood cells (PRBC) within 24 h. We compared PRBC: plasma ratio of > 2:1 (Unbalanced Ratios, UR) versus ≤ 2:1 (Balanced Ratios, BR), hypothesizing decreased risk of mortality with BR. METHODS The Trauma Quality Improvement Program was queried (2014-2016) for PTPs receiving a MT. A multivariable logistic regression model was used to determine risk of mortality. RESULTS From 239 PTPs receiving an MT, 98 (41%) received an UR, whereas 141 (59%) received a BR. The median ratios, respectively, were 2.7:1 and 1.2:1. Compared to BR patients, UR patients had no differences in injury severity score (ISS), hypotension on admission, and intensive care unit stay (all p > 0.05). The mortality rates for BR and UR were similar (46.1% vs. 52.0%, p = 0.366). Controlling for age, ISS, and severe head injury, UR demonstrated similar risk of mortality compared to BR (p = 0.276). Additionally, ≥ 4:1 ratio versus ≤ 2:1 showed no difference in associated risk of mortality (p = 0.489). CONCLUSION In contrast to adult studies, this study demonstrated that MT ratios of > 2:1 and even ≥ 4:1 were associated with similar mortality compared to BR for PTPs. These results suggest pediatric MT resuscitation may not require strict BR as has been shown beneficial in adult trauma patients. Future prospective studies are needed to evaluate the optimal ratio for PTP MT resuscitation. LEVEL OF EVIDENCE III; Retrospective Care Management Study.
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Kinslow K, McKenney M, Boneva D, Elkbuli A. Massive transfusion protocols in paediatric trauma population: A systematic review. Transfus Med 2020; 30:333-342. [DOI: 10.1111/tme.12701] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/10/2020] [Accepted: 05/19/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Kyle Kinslow
- Department of Surgery Kendall Regional Medical Center Miami Florida USA
| | - Mark McKenney
- Department of Surgery Kendall Regional Medical Center Miami Florida USA
- University of South Florida Tampa Florida USA
| | - Dessy Boneva
- Department of Surgery Kendall Regional Medical Center Miami Florida USA
- University of South Florida Tampa Florida USA
| | - Adel Elkbuli
- Department of Surgery Kendall Regional Medical Center Miami Florida USA
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23
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Evangelista ME, Gaffley M, Neff LP. Massive Transfusion Protocols for Pediatric Patients: Current Perspectives. J Blood Med 2020; 11:163-172. [PMID: 32547282 PMCID: PMC7247594 DOI: 10.2147/jbm.s205132] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/24/2020] [Indexed: 01/03/2023] Open
Abstract
In adults, the use of balanced resuscitation and study of massive transfusion protocols have led to improved outcomes for patients and continues to be refined. In children, massive transfusion protocols require further development and study to assess efficacy. Standardization is needed as transfusions and activation of protocols still rely on physician discretion in most pediatric settings. Further research is required to define the pediatric trauma population that will benefit, when to activate these protocols and how to use adjuncts such as tranexamic acid or factor VII in resuscitation. In addition, future implementation of technology such as hemoglobin-based oxygen carriers to increase survival should be studied further in this subset of patients.
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Affiliation(s)
| | - Michaela Gaffley
- General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lucas P Neff
- Pediatric Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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24
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Donahue BS. Red Cell Transfusion and Thrombotic Risk in Children. Pediatrics 2020; 145:peds.2019-3955. [PMID: 32198294 DOI: 10.1542/peds.2019-3955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2019] [Indexed: 01/28/2023] Open
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Phillips R, Acker SN, Shahi N, Meier M, Leopold D, Recicar J, Kulungowski A, Patrick D, Moulton S, Bensard D. The ABC-D score improves the sensitivity in predicting need for massive transfusion in pediatric trauma patients. J Pediatr Surg 2020; 55:331-334. [PMID: 31718872 DOI: 10.1016/j.jpedsurg.2019.10.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 10/14/2019] [Indexed: 01/31/2023]
Abstract
PURPOSE Early and accurate identification of pediatric trauma patients who will require massive transfusion (MT) remains difficult, and MT activation criteria are not well established. In children, the addition of shock index-pediatric age-adjusted (SIPA) to the ABC score (ABC-S) only modestly improves the sensitivity of the ABC score. We hypothesized that the discriminate ability of the ABC-S score would improve with the addition of elevated serum lactate and base deficit (ABCD score). METHODS We identified children between 1 and 18 years old who received a pRBC transfusion between 2008 and 2018 from our trauma registry. We calculated sensitivity, specificity, and accuracy of the ABC, ABC-S, and ABCD scores to determine the need for MT. RESULTS We included 211 children, of which 66 required MT. The best predictor of MT was achieved by adding BD and lactate to the ABC-S score, with an AUC of 0.805. An ABCD score of 3 or greater was 77.4% sensitive and 78.8% specific at predicting the need for MT. Pediatric trauma patients that required MT had higher injury severity score (p = 0.005), lactate (p = 0.002), base deficit (p = <0.0001). Mortality was higher in the MT group (45.5% vs 15.3%, p = 0.0004). CONCLUSIONS The ABCD score improves the sensitivity of activating MT in pediatric trauma patients. STUDY TYPE Treatment Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Maxene Meier
- Children's Hospital Center for Research in Outcomes for Children's Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - David Leopold
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John Recicar
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Ann Kulungowski
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - David Patrick
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
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27
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Rosenfeld E, Lau P, Zhang W, Russell RT, Shah SR, Naik-Mathuria B, Vogel AM. Defining massive transfusion in civilian pediatric trauma. J Pediatr Surg 2019; 54:975-979. [PMID: 30765151 DOI: 10.1016/j.jpedsurg.2019.01.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 01/27/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE The purpose of this study was to identify an optimal definition of massive transfusion (MT) in civilian pediatric trauma. METHODS Severely injured children (age ≤18 years, injury severity score ≥25) in the Trauma Quality Improvement Program research datasets 2014-2015 that received blood products were identified. Children with traumatic brain injury and non-survivable injuries were excluded. Early mortality was defined as death within 24 h and delayed mortality as death after 24 h from hospital admission. Receiver operating curves and sensitivity and specificity analysis identified an MT threshold. Continuous variables are presented as median [IQR]. RESULTS Of the 270 included children, the overall mortality was 27% (N = 74). There were no differences in demographics or mechanism of injury between children that lived or died. Sensitivity and specificity for early mortality was optimized at a 4-h transfusion volume of 37 ml/kg. After controlling for other significant variables, a threshold of 37 ml/kg/4 h predicted the need for a hemorrhage control procedure (OR 8.60; 95% CI 4.25-17.42; p < 0.01) and early mortality (OR 4.24; 95% CI 1.96-9.16; p < 0.01). CONCLUSION An MTP threshold of 37 mL/kg/4 h of transfused blood products predicted the need for hemorrhage control procedures and early mortality. This threshold may provide clinicians with a timely prognostic indicator, improve research methodology, and resource utilization. TYPE OF STUDY Diagnostic Test. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Eric Rosenfeld
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Patricio Lau
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Wei Zhang
- Outcomes & Impact Service, Texas Children's Hospital, Houston, TX
| | - Robert T Russell
- Department of Pediatric Surgery, Children's Hospital of Alabama, Birmingham, AL
| | - Sohail R Shah
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Bindi Naik-Mathuria
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Adam M Vogel
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
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Massive transfusion in the pediatric population: A systematic review and summary of best-evidence practice strategies. J Trauma Acute Care Surg 2019; 86:744-754. [DOI: 10.1097/ta.0000000000002188] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Thomasson RR, Yazer MH, Gorham JD, Dunbar NM. International assessment of massive transfusion protocol contents and indications for activation. Transfusion 2019; 59:1637-1643. [PMID: 30720872 DOI: 10.1111/trf.15149] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/18/2018] [Accepted: 12/28/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Massive transfusion protocols (MTPs) provide blood products rapidly and in fixed amounts. MTPs are commonly used in trauma but may also be used in other clinical settings, although evidence to support fixed-ratio resuscitation in nontraumatic hemorrhage is lacking. The goals of this study were to describe the types and contents of available MTPs and the clinical indications for MTP activation. METHODS A survey was distributed to 353 transfusion medicine specialists to assess the types and contents of available MTPs. Survey participants were invited to provide the clinical indications for consecutive adult and pediatric MTP activations for at least 6 months during 2015 to 2017. RESULTS There were 125 completed surveys (35% response rate) including three from children's specialty hospitals. Most hospitals that treated adult patients (90/122, 74%) utilized only one MTP for all adult bleeding emergencies, while one hospital had no MTP. Of the 31 hospitals that provided more than one adult MTP, 20 provided MTPs specific for obstetric bleeding cases. Of these, 50% (10/20) included at least one pool of cryoprecipitate or fibrinogen concentrate in the first MTP round, compared with 14% (13/90) of the hospitals with one MTP (p = 0.0012). Fifty-seven hospitals provided the clinical indication for 4176 adult and 155 pediatric MTP activations. Although trauma was the single most common indication, the majority of adult (58%) and pediatric (65%) activations were for nontrauma indications. CONCLUSIONS The majority of hospitals use a single MTP to manage massive hemorrhage. The majority of MTP activations were for nontrauma indications.
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Affiliation(s)
- Reggie R Thomasson
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh and the Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
| | - James D Gorham
- Department of Pathology, University of Virginia Health System, Charlottesville, Virginia
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Chin V, Cope S, Yeh CH, Thompson T, Nascimento B, Pavenski K, Callum J. Massive hemorrhage protocol survey: Marked variability and absent in one-third of hospitals in Ontario, Canada. Injury 2019; 50:46-53. [PMID: 30449459 DOI: 10.1016/j.injury.2018.11.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 11/05/2018] [Accepted: 11/09/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Massive hemorrhage protocols (MHP) are critical to standardized delivery of timely, safe, and resource-effective coordinated care for patients with life-threatening bleeding. METHODS A standardized MHP survey was sent to all hospitals (n = 150) in Ontario with a transfusion service. This study aim was to determine the proportion of hospitals with an MHP and assess for variability. RESULTS The overall survey completion rate was 133 of 150 hospitals (89%) (remaining 17 providing negative affirmation that they did not have an MHP). An MHP was in place at 97 of 150 (65%) hospitals (60% of small (<5000 red cell units/year) vs. 91% of medium/large). A total of 10 different names of protocols were reported, with "Massive Transfusion Protocol" (68%) predominating. Activation criteria were present in 82 of 97 (85%); commonly activated based on volume of blood loss (70%). Blood work was drawn at the discretion of the physician (37%) or at predefined intervals (31%; majority every 60 min). Common routine laboratory tests performed were CBC (87%) and INR (84%). Fibrinogen testing was available at 88 (66%) of 133 reporting hospitals and part of the standard testing at 73 of 97 (75%) hospitals with an MHP. Median targets of hemostatic resuscitations, stated in the protocol at 49% of hospitals with an MHP, were: platelets >50 × 109/L, INR < 1.8, fibrinogen >1.5 g/L, and hemoglobin >70 g/L. Protocol required patient temperature monitoring in 65% and specified a reversal plan for patients on anticoagulants in 59%. At 36% of sites all patients are initially managed with O RhD negative blood. Overall, 61% of sites issue blood in predefined packs (vs. on demand). Hemostatic agents in protocols included: tranexamic acid (70%), prothombin complex concentrate (14%), fibrinogen concentrate (13%), and recombinant FVIIa (4%). Quality metrics were tracked in 32% of hospitals. CONCLUSIONS A third of hospitals lack formal MHPs, with the majority lacking in smaller hospitals. The survey results indicate that there is marked variability in all key aspects of the reported MHPs. This may be due to differences in hospital resources and personnel, lack of supporting evidence to dictate requirements, and differences in knowledge base of the individuals involved in protocol setting.
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Affiliation(s)
| | - Stephanie Cope
- Ontario Regional Blood Coordinating Network, Toronto, Canada
| | - Calvin Hsiung Yeh
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Canada
| | - Troy Thompson
- Ontario Regional Blood Coordinating Network, Toronto, Canada
| | - Barto Nascimento
- Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Surgery, Sunnybrook Health Sciences Centre, Canada
| | - Katerina Pavenski
- Laboratory Medicine and Pathology, University of Toronto, Canada; St. Michael's Hospital, Toronto, Canada
| | - Jeannie Callum
- Sunnybrook Health Sciences Centre, Toronto, Canada; Laboratory Medicine and Pathology, University of Toronto, Canada.
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31
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Abstract
PURPOSE OF REVIEW Trauma is the most common cause of pediatric mortality. Much of the research that led to life-saving interventions in adults, however, has not been replicated in the pediatric population. Children have important physiologic and anatomic differences from adults, which impact hemostasis and transfusion. Hemorrhage is a leading cause of death in trauma, and children have important differences in their coagulation profiles. Transfusion strategies, including the massive transfusion protocol and use of antifibrinolytics, are still controversial. In addition to the blood that is lost from the injury itself, trauma leads to inflammation and to a dysfunction in hemostasis, causing coagulopathy. RECENT FINDINGS In one study in which children suffered from mainly blast and penetrating injuries in a combat setting (PEDTRAX trial), the early administration of tranexamic acid was associated with decreased mortality. Some authors suggest that this result may not apply to blunt trauma, which is much more common in children in noncombat settings. Using thromboelastography to guide the administration of recombinant Factor VIIa has been done in selected cases and may represent a future avenue of research. SUMMARY This article explores new research from the past year in pediatric trauma, starting with the physiologic differences in pediatric red blood cells and coagulation profiles. We also looked at the dramatic change in thinking over the past decade in the tolerable level of anemia in critically ill pediatric patients, as well as scales for determining the need for massive transfusion and exploring if the concepts of damage control resuscitation apply to children. Other strategies, such as avoiding hypothermia, and the selective administration of antifibriniolytics, are important in pediatric trauma as well. Future research that is pediatric focused is needed for the optimal care of our youngest patients.
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32
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Cunningham ME, Rosenfeld EH, Zhu H, Naik-Mathuria BJ, Russell RT, Vogel AM. A High Ratio of Plasma: RBC Improves Survival in Massively Transfused Injured Children. J Surg Res 2018; 233:213-220. [PMID: 30502251 DOI: 10.1016/j.jss.2018.08.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/02/2018] [Accepted: 08/01/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Massive transfusion protocols with balanced blood product ratios have been associated with improved outcomes in adult trauma. The impact on pediatric trauma is unclear. MATERIAL AND METHODS A retrospective review of the Pediatric Trauma Quality Improvement Program data set was performed using data from January 2015 to December 2016. Trauma patient's ≤ 18 y of age, who received red blood cells (RBCs) and were massively transfused were included. Children with burns, dead on arrival, and nonsurvivable injuries were excluded. Outcome data and mortality were assessed based on low (<1:2), medium (≥1:2, <1:1), and high (≥1:1) plasma and platelet to RBC ratios. RESULTS There were 465 children included in the study (median age, 8 [2-16] y; median injury severity score, 34 [29-34]; mortality rate, 38%). Those transfused a medium plasma:RBC ratio received the greatest blood product volume in 24 h (90 [56-164] mL/kg; P < 0.01). Those in the low plasma:RBC group underwent fewer hemorrhage control procedures [56 (34%); P < 0.01], but ratio was not significant when controlling for age and other variables. Survival was improved for those who received a high plasma:RBC ratio (P = 0.02). Platelet transfusions were skewed toward lower ratios (95%) with no difference in clinical outcomes between the groups. CONCLUSIONS A high ratio of plasma:RBC may result in decreased mortality in severely injured children receiving a massive transfusion. Prospective, multicenter studies are needed to determine optimal resuscitation strategies for these critically ill children.
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Affiliation(s)
- Megan E Cunningham
- Department of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | - Eric H Rosenfeld
- Department of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | - Huirong Zhu
- Department of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | | | - Robert T Russell
- Department of Pediatric Surgery, Children's of Alabama, Birmingham, Alabama
| | - Adam M Vogel
- Department of Pediatric Surgery, Texas Children's Hospital, Houston, Texas.
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33
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Hwu RS, Keller MS, Spinella PC, Baker D, Shi J, Leonard JC. Identifying potential predictive indicators of massive transfusion in pediatric trauma. TRAUMA-ENGLAND 2018. [DOI: 10.1177/1460408617721729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Ruth S Hwu
- Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Division of Pediatric Emergency Medicine, Emory University Atlanta, GA, USA
| | - Martin S Keller
- Division of Pediatric Surgery, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Philip C Spinella
- Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - David Baker
- St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Junxin Shi
- Nationwide Children’s Hospital, Columbus, OH, USA
| | - Julie C Leonard
- Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Division of Pediatric Emergency Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
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34
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Affiliation(s)
- C. Booth
- Barts Health NHS Trust; London UK
| | - S. Allard
- Barts Health NHS Trust; London UK
- NHS Blood and Transplant; London UK
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35
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Piteau S. Update in Pediatric Emergency Medicine: Pediatric Resuscitation, Pediatric Sepsis, Interfacility Transport of the Pediatric Patient, Pain and sedation in the Emergency Department, Pediatric Trauma. UPDATE IN PEDIATRICS 2018. [PMCID: PMC7123355 DOI: 10.1007/978-3-319-58027-2_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Shalea Piteau
- Chief/Medical Director of Pediatrics at Quinte Health Care, Assistant Professor at Queen’s University, Belleville, Ontario Canada
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36
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Roberts DJ. Expanding access to Transfusion Medicine and improving practice: guidelines, patient blood management, protocols and products. Transfus Med 2017; 27 Suppl 5:315-317. [PMID: 29076249 DOI: 10.1111/tme.12484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- D J Roberts
- National Health Service Blood and Transplant, University of Oxford, John Radcliffe Hospital, Oxford, UK
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37
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Abstract
Following results from the CRASH-2 trial, tranexamic acid (TXA) gained considerable interest for the treatment of hemorrhage in trauma patients. Although TXA is effective at reducing mortality in patients presenting within 3 hours of injury, optimal dosing, timing of administration, mechanism, and pharmacokinetics require further elucidation. The concept of fibrinolysis shutdown in hemorrhagic trauma patients has prompted discussion of real-time viscoelastic testing and its potential role for appropriate patient selection. The results of ongoing clinical trials will help establish high-quality evidence for optimal incorporation of TXA in mature trauma networks in the United States and abroad.
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Affiliation(s)
- Ricardo J Ramirez
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Philip C Spinella
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Grant V Bochicchio
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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38
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Hwu RS, Spinella PC, Keller MS, Baker D, Wallendorf M, Leonard JC. The effect of massive transfusion protocol implementation on pediatric trauma care. Transfusion 2016; 56:2712-2719. [PMID: 27572499 DOI: 10.1111/trf.13781] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 07/07/2016] [Accepted: 07/15/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND Massive transfusion protocols (MTPs) to address hemorrhage are understudied in children. The objective was to determine the effect of MTP implementation on outcomes of injured children. STUDY DESIGN AND METHODS This was a retrospective comparison of injured children before and after MTP implementation for children less than 18 years old who presented in 2005 to 2014 and received red blood cells (RBCs) within 24 hours of arrival. Children were divided into groups based on pre-/post-MTP implementation and subgrouped based on receipt of massive transfusion (≥40 mL/kg RBCs or ≥80 mL/kg total blood products at 24 hr from arrival). The primary outcome was in-hospital mortality and secondary outcomes were total blood product use, intensive care unit/ventilator/pressor-free days, composite morbidity, and Glasgow Outcome Score. RESULTS A total of 11,995 children presented for trauma care over 9 years; 235 received RBCs. A total of 120 were in the pre-MTP group and 115 in the post-MTP, of whom 26 and 17 received massive transfusion in the pre- and post-MTP groups, respectively; 11 had MTP activations. Children massively transfused after MTP received mean plasma:RBC and platelet (PLT):RBC ratios greater than 1:1 at both 6 and 24 hours with no significant difference in total admission blood product use. There was no difference in in-hospital mortality between pre- and post-MTP groups (24% vs. 19%) or massive transfusion subgroups (54% vs. 47%). There were no differences in secondary outcomes. CONCLUSIONS While we were not able to show improvements in outcome, MTP implementation led to higher plasma and PLT:RBC ratios without an associated change in blood product use or composite morbidity.
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Affiliation(s)
- Ruth S Hwu
- St Louis Children's Hospital.,Emory University School of Medicine, Atlanta, Georgia
| | - Philip C Spinella
- St Louis Children's Hospital.,Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Martin S Keller
- St Louis Children's Hospital.,Washington University in St Louis School of Medicine, St Louis, Missouri
| | | | - Michael Wallendorf
- Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Julie C Leonard
- St Louis Children's Hospital.,Washington University in St Louis School of Medicine, St Louis, Missouri.,Nationwide Children's Hospital, Columbus, Ohio
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39
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Abstract
Massive transfusions occur frequently in pediatric trauma patients, among some children undergoing surgery, or in children with critical illness. Over the last years, many authors have studied different aspects of massive transfusions, starting with an operative definition. Some information is available on transfusion strategies and adjunctive treatments. Areas that require additional investigation include: studies to assess which children benefit from transfusion protocols based on fixed ratios of blood components vs transfusion strategies based on biophysical parameters and laboratory tests; whether goal-directed therapies that are personalized to the recipient will improve outcomes; or which laboratory tests best define the risk of bleeding and what clinical indicators should prompt the start and stop of massive transfusion protocols. In addition, critical issues that require further study include transfusion support with whole blood vs reconstituted whole blood prepared from packed red blood cells, plasma, and platelets; and the generation of high quality evidence that would lead to treatments which decrease adverse consequences of transfusion and improve outcomes.
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Affiliation(s)
- Oliver Karam
- Pediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland.
| | - Marisa Tucci
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, Canada.
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