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Massive transfusion protocols in paediatric trauma population: A systematic review
Kyle Kinslow1, Mark McKenney1,2, Dessy Boneva1,2
1Department of Surgery, Kendall Regional Medical Center, Miami, Florida, USA.
Insights
Paediatric massive transfusion (PMT) protocols lack a clear definition and optimal blood product ratios. While PMT implementation shows benefits in reducing transfusion times, evidence for improved paediatric trauma mortality remains limited, though morbidity may decrease.
Area of Science:
- Pediatric Emergency Medicine
- Trauma Resuscitation
- Blood Transfusion Practices
Background:
- Paediatric massive transfusion (PMT) protocols are critical in managing severe hemorrhage in children.
- Existing literature lacks consensus on PMT definition, optimal blood product ratios, and overall outcomes.
Purpose of the Study:
- To review the literature and define paediatric massive transfusion (PMT).
- To identify investigated blood product ratios and their impact on paediatric outcomes.
- To evaluate existing evidence on PMT outcomes in children.
Main Methods:
- Systematic literature review following PRISMA guidelines.
- Searched multiple databases including PubMed, Google Scholar, and EMBASE.
- Included articles were assessed for study design, PMT definition, activation criteria, and transfusion ratios.
Main Results:
- 33 articles were included from 3213 initial searches.
- PMT definitions vary, primarily based on volume/kg but with differing timeframes.
- Some studies suggest improved paediatric mortality with balanced transfusion ratios (1:1 FFP:pRBC), but evidence is limited. PMT implementation did not consistently reduce paediatric trauma mortality but improved operational aspects like time to first transfusion.
Conclusions:
- A clear consensus on PMT definition is lacking; early recognition definitions show promise.
- Evidence for an optimal blood product ratio in PMT is insufficient, though balanced ratios appear favorable.
- PMT protocols have not consistently improved paediatric trauma mortality but may reduce morbidity and improve transfusion timeliness.
Background:
Our main objective was to review the literature to answer the following questions regarding paediatric massive transfusion (PMT) protocols: (a) How is PMT defined?; (b) Which blood product ratios have been investigated, and what is their effect on outcomes?; and (c) What evidence exists regarding PMT outcomes?
Methods:
The PRISMA guidelines were used. We searched PubMed, Google Scholar, Cochrane Library, EMBASE, Wiley Online Library and Ovid. Articles were screened for inclusion based on relevance to PMT. Articles were assessed for study design, presence of established/tested PMT, PMT definition, PMT activation criteria and Transfusion Ratios for the final determination of article inclusion.
Results:
Our search produced 3213 articles, with 33 included for final review. Existing definitions of PMT are based on volume administered/kg but vary in timeframe criteria (over 4 hours vs 24 hours). Some studies have investigated "high" balanced transfusion ratios as seen in adults (1:1 FFP:pRBC), with a few showing statistically significant improvement in paediatric mortality vs lower ratios. PMT protocol implementation has not been shown to consistently reduce paediatric trauma mortality across multiple centres. However, other operational aspects, such as reduced time to first transfusion, are apparent benefits.
Conclusions:
There is poor consensus over the definition of PMT. Definitions that involve early recognition have the most promise for practice and future studies. Evidence supporting an optimal blood product ratio in PMT is also lacking but trends towards supporting balanced approaches. Implementation of PMT protocols has been limited in showing significant improvement of overall paediatric trauma mortality but may reduce associated morbidity.
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