Massive transfusion and blood product use in the pediatric trauma patient.
ABSTRACT Hemorrhagic shock in the pediatric trauma patient is an uncommon but fundamental problem for the treating clinician. Current management of hemorrhagic shock involves initial resuscitation with crystalloid fluids followed by infusion of blood components as necessary. In management of the adult trauma patient, many institutions have implemented massive transfusion protocols to guide transfusion in situations requiring or anticipating the use of greater than 10 U of packed red blood cells. In the pediatric population, guidelines for massive transfusion are vague or nonexistent. Adult trauma transfusion protocols can be applied to children until a pediatric protocol is validated. Here, we attempt to identify certain principles of transfusion therapy specific to pediatric trauma and outline a sample pediatric massive transfusion protocol that may be used to guide resuscitation. Also, adjuncts to transfusion, such as colloid fluids, other plasma expanders or hemoglobin substitutes, and recombinant activated factor VII, are discussed.
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ABSTRACT: Our rural trauma center uses packed red blood cells (PRBCs) and plasma onboard our helicopter to offset the delay of transport. We summarize our initial experience with prehospital blood use in pediatric trauma patients. Our air ambulance service began carrying PRBCs in 1987 and plasma in 2009. We performed a 9-year retrospective review including patients (< 18 years) who received blood during helicopter transports. Only patients transported to our level 1 trauma center were included to ensure complete follow-up. Sixteen patients (6 females) were identified with a mean age of 13 years. The mean transport time was 30 minutes with 75% transferred in from a referring center. Injuries were blunt in 9 patients and penetrating in 2 patients. The mean Injury Severity Score was 30. Fifteen patients received an average of 1.5 units of PRBCs during flight. Indications for PRBCs were severe anemia (6), known blood loss (5), and nonresponder to intravenous fluids (4). Average hemoglobin improved from 9.4 to 11.4 mg/dL at our center. Base deficit improved from -7 to -5.7 at arrival. Five patients received a mean of 1.4 units of plasma. The arrival international normalized ratio was 1.4. The average length of stay was 9.3 days. Four patients died. Trauma Related Injury Severity Score showed 3 patients were unexpected survivors (0.24, 0.24, and 0.38). Prehospital use of blood in injured children is rare. However, when indicated, this initial review of our protocol showed increased hemoglobin, decreased acidosis, and unexpected survivors with our program. Because of the rarity of prehospital blood use in children, administration triggers require continued review and refinement. Copyright © 2015 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.Journal of Air Medical Transport 01/2015; 34(1):40-43. DOI:10.1016/j.amj.2014.07.037
Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 12/2015; 23(1). DOI:10.1186/s13049-015-0097-z · 1.93 Impact Factor
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ABSTRACT: Component balanced resuscitation and avoidance of crystalloids in traumatically injured adults requiring massive transfusion are beneficial. Evidence for children is lacking. After institutional review board approval was obtained, the Department of Defense Trauma Database identified 1,311 injured children 14 years or younger requiring transfusion after an injury and admitted to a deployed US military hospital from 2002 to 2012. Logistic regression determined risk factors for high-volume (≥40 mL/kg) or massive (≥70 mL/kg) transfusions. The effects of crystalloid and balanced component resuscitation in the first 24 hours were assessed. Nine hundred seven patients had recorded data sufficient for analysis. Two hundred twenty-four children received high-volume transfusion, and 77 received massive transfusions. Mortality was significantly higher for massive transfusions and high-volume transfusions than others (25% vs. 10% and 19% vs. 9%, respectively). Age of less than 4 years, penetrating injury, and Injury Severity Score (ISS) greater than 15 were associated with high-volume transfusions; an ISS greater than 15 and penetrating injury were associated with massive transfusions. Increased crystalloid administration showed a significant positive association with hospital days and intensive care unit days for both massive and high-volume transfusions, as well as a significant positive association with increased ventilator days in patients with high-volume transfusions. Balanced component resuscitation was not associated with improved measured outcomes and was independently associated with a higher mortality when all transfused patients were considered. In this cohort, heavy reliance on crystalloid for resuscitation had an adverse effect on outcomes. Balanced component resuscitation did not improve outcomes and was associated with higher mortality when all transfused patients were considered. Further study is needed regarding efficacy and clinical triggers for the implementation of massive transfusion in children. Prognostic study, level IV.Journal of Trauma and Acute Care Surgery 02/2015; 78(2):330-335. DOI:10.1097/TA.0000000000000469 · 1.97 Impact Factor