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The evolution of pediatric transfusion practice during combat operations 2001-2013
Jeremy W Cannon1, Lucas P Neff, Heather F Pidcoke
1From the Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (J.W.C.); Uniformed Services University of the Health Sciences, Bethesda, MD (J.W.C., A.P.C., M.A.B.); Department of Pediatric Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA (L.P.N.); Terumo BCT, Lakewood, CO (H.F.P.); Graduate Medical Education, San Antonio Military Medical Center, JBSA Fort Sam Houston, TX (J.K.A.); Department of Pediatrics, Washington University School of Medicine, St. Louis, MO (P.C.S.); Department of Emergency Medicine, University of California, Davis, CA (M.A.J.); US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX (A.P.C.); and Department of Pediatrics, San Antonio Military Medical Center, JBSA Fort Sam Houston, TX (M.A.B.).
Insights
Pediatric combat trauma resuscitation shifted to a hemostatic approach, with increased transfusions and stable mortality despite severe injuries. Massive transfusion patients showed decreased mortality over time.
Area of Science:
- Trauma Resuscitation
- Pediatric Critical Care
- Military Medicine
Background:
- Hemostatic resuscitation principles have transformed adult trauma care.
- Pediatric resuscitation practices have evolved but remain unquantified.
- This study evaluates changes in pediatric resuscitation within a combat trauma system.
Purpose of the Study:
- To quantify changes in pediatric resuscitation practices over time.
- To assess the impact of these changes on patient outcomes.
- To compare early and late resuscitation cohorts in a combat setting.
Main Methods:
- Analysis of the Department of Defense Trauma Registry (2001-2013) for pediatric patients.
- Exclusion of burn, drowning, and missing injury severity score cases.
- Calculation of fluid and blood product volumes, tranexamic acid use, and comparison of outcomes between early and late cohorts.
Main Results:
- Increased severity of injuries, including explosion-related trauma and head injuries, was observed over time.
- Significant increases in transfused (TX+) and massively transfused (MT+) patients were noted.
- Despite increased injury severity, overall mortality remained stable, and mortality decreased in MT+ patients.
Conclusions:
- Pediatric combat casualty care has adopted a more hemostatic transfusion approach.
- Mortality remained low and stable, decreasing in massively transfused patients despite more severe injuries.
- Further research is needed to optimize resuscitation for critically injured children.
Background:
Hemostatic resuscitation principles have significantly changed adult trauma resuscitation over the past decade. Practice patterns in pediatric resuscitation likely have changed as well; however, this evolution has not been quantified. We evaluated pediatric resuscitation practices over time within a combat trauma system.
Methods:
The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric patients (<18 years). Patients with burns, drowning, and missing injury severity score were excluded. Volumes of crystalloid, packed red blood cells (PRBC), whole blood, plasma, and platelets (PLT) given in the first 24 hours were calculated per kilogram body weight. Tranexamic acid use was also determined. Patients were divided into Early (2001-2005) and Late (2006-2013) cohorts, and subgroups of transfused (TX+) and massively transfused (MT+) patients were created. Intensive care unit and hospital length of stay and 24-hour and in-hospital mortality rates were compared.
Results:
A total of 4,358 patients met inclusion criteria. Comparing Early versus Late, injuries from explosions, isolated or predominant head injuries, and injury severity score all increased. The proportion of TX+ patients also increased significantly (13.6% vs 37.4%, p < 0.001) as did the number of MT+ patients (2.1% vs 15.5%, p < 0.001). Transfusion of high plasma:RBC and PLT:RBC ratios increased in both the TX+ and MT+ subgroups, although overall, PLT and whole blood use was low. After adjusting for differences between groups, the odds of death was no different Early versus Late but decreased significantly in the MT+ patients with time as a continuous variable.
Conclusion:
Transfusion practice in pediatric combat casualty care shifted toward a more hemostatic approach over time. All-cause mortality was low and remained stable overall and even decreased in MT+ patients despite more injuries due to explosions, more head injuries, and greater injury severity. However, further study is required to determine the optimal resuscitation practices in critically injured children.
Level Of Evidence:
Epidemiologic study, level IV.
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