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Development of transfusion guidelines for injured children using a Modified Delphi Consensus Process
A Francois Trappey1, Kyle M Thompson, Nathan Kuppermann
1From the David Grant Air Force Medical Center (A.F.T.), Travis Air Force Base, Fairfield, California; Division of Trauma and Acute Care Surgery (A.F.T.), General Surgery Residency Program (K.M.T.), Department of Surgery, Emergency Medicine and Pediatrics (N.K.), UC Davis Health System, Division of Pediatric General and Thoracic Surgery (J.T.S.), Division of Public Health Sciences (M.A.N.), University of California at Davis, Davis, California; Division of Pediatric Emergency Medicine (H.A.H.), Primary Children's Hospital, University of Utah Health, Salt Lake City, Utah; Department of Emergency Medicine (S.R.M.), Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania; Emergency Medicine (R.M.S.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio; Department of Emergency Medicine, Trauma, Acute Care Surgery and Surgical Critical Care (J.M.G.), and Division of Emergency Medicine (D.K.N.), University of California at Davis, Davis, California.
Insights
Consensus-based transfusion guidelines were developed for pediatric trauma patients to standardize care. These guidelines aim to reduce variability in transfusion practices for children with hemorrhagic injuries in clinical trials.
Area of Science:
- Pediatric Trauma Care
- Clinical Trial Standardization
- Hemorrhagic Injury Management
Background:
- Significant variability exists in pediatric transfusion practices for hemorrhagic injuries.
- Standardizing transfusion protocols is crucial for multicenter pediatric trauma clinical trials.
- A consensus-based approach was needed to develop guidelines for an upcoming trial on tranexamic acid in children.
Purpose of the Study:
- To develop consensus-based transfusion guidelines for pediatric trauma patients.
- To minimize confounding factors in a multicenter randomized clinical trial.
- To standardize transfusion practices across participating trauma centers.
Main Methods:
- A modified Delphi process was employed with a multidisciplinary expert panel.
- A survey assessed 23 categories of transfusion practices using a 5-point Likert scale.
- Consensus was defined as ≥80% agreement; four survey iterations were conducted.
Main Results:
- 35 panelists from four pediatric trauma centers participated.
- 176 statements were rated across 23 categories.
- 39 statements were accepted, forming the basis for transfusion guidelines and an algorithm.
Conclusions:
- Consensus-based transfusion guidelines were successfully developed for pediatric hemorrhagic injuries.
- These guidelines will help standardize practices in a clinical trial evaluating tranexamic acid.
- Broad interdisciplinary participation ensured comprehensive guideline development.
Background:
There is wide variability of transfusion practices for children with hemorrhagic injuries across trauma centers. We are planning a multicenter, randomized clinical trial evaluating tranexamic acid in children with hemorrhage. Standardization of transfusion practices across sites is important to minimize confounding. Therefore, we sought to generate consensus-based transfusion guidelines for the trial.
Methods:
We used a modified Delphi process utilizing a multi-site, multi-disciplinary panel of experts to develop our transfusion guidelines. A survey of 23 clinical categories on various aspects of transfusion practices was developed and distributed via SurveyMonkey®. Statements were graded on a 5-point Likert scale ("Strongly agree" to "This intervention may be harmful"). Statements were accepted if ≥ 80% of the panelists rated the statement as "Strongly agree" or "Agree". After each round, the responses were calculated and the results included on subsequent rounds.
Results:
35 panelists from four pediatric trauma centers participated in the study, including 11 (31%) pediatric EM physicians, 8 (23%) pediatric trauma surgeons, 5 (14%) transfusionists, 5 (14%) pediatric anesthesiologists, and 6 (17%) pediatric critical care physicians (range of 8 to 10 from each clinical site). Four survey iterations were performed. In total 176 statements were rated and 39 were accepted by criteria across all 23 categories. An rational algorithm for transfusion in trauma was then developed.
Conclusions:
We successfully developed transfusion guidelines for various aspects of the management of children with hemorrhagic injuries using a modified Delphi process with broad interdisciplinary participation. We anticipate implementation of these guidelines will help minimize heterogeneity of transfusion practices across clinical sites for the upcoming clinical trial evaluating tranexamic acid in children with hemorrhage.
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