Use of whole blood in pediatric trauma: a narrative review

Whole blood to total transfusion volume ratio in injured children: A national database analysis

BACKGROUND

Whole blood (WB) resuscitation is increasingly common in adult trauma centers and some pediatric trauma centers, as studies have noted its safety and potential superiority to component therapy (CT). Previous analyses have evaluated WB as a binary variable (any versus none), and little is known regarding the "dose response" of WB in relation to total transfusion volume (TTV) (WB/TTV ratio).

METHODS

Injured children younger than 18 years who received any blood transfusion within 4 hours of hospital arrival across 456 US trauma centers were included from the American College of Surgeons Trauma Quality Improvement Program database. The primary outcome was 24-hour mortality, and the secondary outcome was 4-hour mortality. Multivariate analysis was used to evaluate associations between WB administration and mortality and WB/TTV ratio and mortality.

RESULTS

Of 4,323 pediatric patients included in final analysis, 88% (3,786) received CT only, and 12% (537) received WB with or without CT. Compared with the CT group, WB recipients were more likely to be in shock, according to pediatric age-adjusted shock index (71% vs. 60%) and had higher median (interquartile range) Injury Severity Score (26 [17-35] vs. 25 [16-24], p = 0.007). Any WB transfusion was associated with 42% decreased odds of mortality at 4 hours (adjusted odds ratio [aOR], 0.58 [95% confidence interval, 0.35-0.97]; p = 0.038) and 54% decreased odds of mortality at 24 hours (aOR, 0.46 [0.33-0.66]; p < 0.001). Each 10% increase in WB/TTV ratio was associated with a 9% decrease in 24-hour mortality (aOR, 0.91 [0.85-0.97]; p = 0.006). Subgroup analyses for age younger than 14 years and receipt of massive transfusion (>40 mL/kg) also showed statistically significant survival benefit for 24-hour mortality.

CONCLUSION

In this retrospective American College of Surgeons Trauma Quality Improvement Program analysis, use of WB was independently associated with reduced 24-hour mortality in children; further, higher proportions of WB used over the total resuscitation (WB/TTV ratio) were associated with a stepwise increase in survival.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Fifteen-minute consultation: a guide to paediatric major haemorrhage

Major trauma is a principal cause of morbidity and mortality in children. Severe haemorrhage is the second-leading cause of death in paediatric trauma, preceded by traumatic brain injury. Major haemorrhage protocols (MHPs), also known as 'code red' and 'massive transfusion protocols', are used to make large volumes of blood products rapidly available. Most recommendations for paediatric MHPs are extrapolated from adult data because of a lack of large, high-quality, prospective paediatric studies. However, applying adult data in a paediatric context requires caution due to differences in injury mechanisms and physiological responses between adults and children. Since major haemorrhage is a high-acuity low-occurrence event, MHP requires effective training, collaboration and communication among a large multidisciplinary team.In this 15-minute consultation, we provide an evidence-based synthesis of the management principles of paediatric major haemorrhage.

Receipt of RhD-positive whole blood for life-threatening bleeding in female children: A survey in alloimmunized mothers regarding minimum acceptable survival benefit relative to risk of maternal alloimmunization to anti-D

BACKGROUND

Low-titer group O whole blood (LTOWB) for treatment of hemorrhagic shock sometimes necessitates transfusion of RhD-positive units due to short supply of RhD-negative LTOWB. Practitioners must choose between using RhD-positive LTOWB when RhD-negative is unavailable against the risk to a female of childbearing potential of becoming RhD-alloimmunized, risking hemolytic disease of the fetus and newborn (HDFN) in future children, or using component therapy with RhD-negative red cells. This survey asked females with a history of red blood cell (RBC) alloimmunization about their risk tolerance of RhD alloimmunization compared to the potential for improved survival following transfusion of RhD-positive blood for an injured RhD negative female child.

STUDY DESIGN AND METHODS

A survey was administered to RBC alloimmunized mothers. Respondents were eligible if they were living in the United States with at least one red cell antibody known to cause HDFN and if they had at least one RBC alloimmunized pregnancy.

RESULTS

Responses from 107 RBC alloimmmunized females were analyzed. There were 32/107 (30%) with a history of severe HDFN; 12/107 (11%) had a history of fetal or neonatal loss due to HDFN. The median (interquartile range) absolute improvement in survival at which the respondents would accept RhD-positive transfusions for a female child was 4% (1%-14%). This was not different between females with and without a history of severe or fatal HDFN (p = .08 and 0.38, respectively).

CONCLUSION

Alloimmunized mothers would accept the risk of D-alloimmunization in a RhD-negative female child for improved survival in cases of life-threatening bleeding.