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Effects of a restrictive blood transfusion protocol on acute pediatric burn care: Transfusion threshold in pediatric
Charles D Voigt1, Gabriel Hundeshagen, Ioannis Malagaris
1From the Department of Surgery (C.D.V., G.H., I.M., R.N.O., H. H., L.C.W., K.D.C., J.O.L., O.A.N.L., J.C.D., L.K.B., W.B.N., C.C.F., D.N.H.), University of Texas Medical Branch; Shriners Hospitals for Children®-Galveston (C.D.V., G.H., I.M., R.N.O., H. H., L.C.W., K.D.C., J.O.L., O.A.N.L., J.C.D., L.K.B., W.B.N., C.C.F., D.N.H.), Galveston, Texas; Department of Surgery (C.D.V.), Creighton University, Omaha, Nebraska; Department of Hand, Plastic and Reconstructive Surgery (G.H.), Burn Trauma Center, BG Trauma Center Ludwigshafen; University of Heidelberg, Ludwigshafen, Germany; School of Allied Health Sciences (K.W.), Baylor College of Medicine, Houston, Texas; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery (J.C.D., L.K.B., D.N.H.), Medical University of Graz, Austria; and Institute for Translational Sciences (J.O.L.,C.C.F.,), University of Texas Medical Branch, Galveston, Texas.
Insights
Implementing a lower hemoglobin threshold for blood transfusions in pediatric burn patients is safe and effective. This approach reduces blood product administration, potentially lowering transfusion risks and healthcare costs.
Area of Science:
- Pediatric critical care medicine
- Burn management
- Transfusion medicine
Background:
- Blood transfusions carry significant medical risks and costs.
- Restrictive transfusion protocols in critically ill patients show medical and economic benefits.
- Pediatric burn patients represent a unique population for evaluating transfusion strategies.
Purpose of the Study:
- To assess the impact of lowering the hemoglobin transfusion threshold in pediatric burn patients.
- To evaluate changes in blood product administration and patient outcomes.
- To determine the safety and efficacy of a restrictive transfusion protocol in this cohort.
Main Methods:
- Retrospective review comparing pediatric burn patients before and after a hemoglobin threshold change (10 g/dL to 7 g/dL).
- Primary endpoints included hemoglobin levels, blood product volume, and mortality.
- Secondary endpoints assessed sepsis incidence and duration, with statistical adjustments for covariates.
Main Results:
- Comparable baseline characteristics and hemoglobin levels between groups.
- Lower blood product volumes administered in the restrictive threshold group during operations and non-surgical days (p < 0.001).
- Significantly lower mortality in the restrictive threshold group (8.0% vs. 3.9%, p < 0.05) with a comparable incidence of sepsis but fewer sepsis days.
Conclusions:
- Restrictive transfusion protocols are safe and effective in pediatric burn patients.
- Reduced blood product use may mitigate transfusion-related risks and decrease economic burden.
- Lowering the hemoglobin threshold is a viable strategy for optimizing care in this population.
Background:
Blood transfusion is costly and associated with various medical risks. Studies in critically ill adult and pediatric patients suggest that implementation of more restrictive transfusion protocols based on lower threshold hemoglobin concentrations can be medically and economically advantageous. The purpose of this study was to evaluate the implications of a hemoglobin threshold change in pediatric burn patients.
Methods:
We implemented a change in hemoglobin threshold from 10 g/dL to 7 g/dL and compared data from patients before and after this protocol change in a retrospective review. Primary endpoints were hemoglobin concentration at baseline, before transfusion, and after transfusion; amount of blood product administered; and mortality. Secondary endpoints were the incidence of sepsis based on the American Burn Association physiological criteria for sepsis and mean number of septic days per patient. All endpoint analyses were adjusted for relevant clinical covariates via generalized additive models or Cox proportional hazard model. Statistical significance was accepted at p less than 0.05.
Results:
Patient characteristics and baseline hemoglobin concentrations (pre, 13.5 g/dL; post, 13.3 g/dL; p > 0.05) were comparable between groups. The group transfused based on the more restrictive hemoglobin threshold had lower hemoglobin concentrations before and after transfusion throughout acute hospitalization, received lower volumes of blood during operations (pre, 1012 mL; post, 824 mL; p < 0.001) and on days without surgical procedures (pre, 602 mL; post, 353 mL; p < 0.001), and had a lower mortality (pre, 8.0%; post, 3.9%; mortality hazard decline, 0.55 [45%]; p < 0.05). Both groups had a comparable incidence of physiological sepsis, though the more restrictive threshold group had a lower number of sepsis days per patient.
Conclusion:
More restrictive transfusion protocols are safe and efficacious in pediatric burn patients. The associated reduction of transfused blood may lessen medical risks of blood transfusion and lower economic burden.
Level Of Evidence:
Therapeutic, level IV.
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