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Life-Threatening Bleeding in Children: A Prospective Observational Study
Julie C Leonard1, Cassandra D Josephson2, James F Luther3
1Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH.
Insights
This study describes children with life-threatening bleeding, finding that mortality is high and death from hemorrhage occurs rapidly, especially in medically caused bleeding. Outcomes vary significantly by bleeding etiology in pediatric patients.
Area of Science:
- Pediatric critical care medicine
- Hemorrhagic shock management
- Transfusion medicine
Background:
- Life-threatening bleeding in children is a critical medical emergency requiring prompt recognition and management.
- Understanding the characteristics and outcomes associated with different etiologies of severe pediatric bleeding is essential for improving patient care.
- Previous studies have not comprehensively described the spectrum of life-threatening bleeding in a large pediatric cohort across multiple international centers.
Purpose of the Study:
- To characterize children experiencing life-threatening bleeding events.
- To compare patient demographics, clinical presentations, interventions, and outcomes based on the etiology of bleeding (trauma, operative, medical).
- To identify factors associated with mortality in this vulnerable pediatric population.
Main Methods:
- Prospective observational study conducted across 24 children's hospitals in the US, Canada, and Italy.
- Included children aged 0-17 years with life-threatening bleeding, defined by high transfusion volume or massive transfusion protocol activation.
- Collected data on patient characteristics, bleeding etiology, therapies administered, and clinical outcomes, including mortality.
Main Results:
- A total of 449 children were enrolled; 46.1% had trauma-related bleeding, 34.1% operative, and 19.8% medical.
- Children with medical bleeding had higher mortality (65.2%) and higher Pediatric Risk of Mortality scores compared to trauma and operative groups.
- High rates of acute respiratory distress syndrome (20.3%) and acute kidney injury (18.5%) were observed; 28-day mortality was 37.5%, with hemorrhage deaths occurring rapidly (86.5% within 24 hours).
Conclusions:
- Patient characteristics and outcomes in life-threatening pediatric bleeding are significantly influenced by the underlying cause.
- Mortality rates are high in children with life-threatening bleeding, particularly those with medical etiologies.
- Hemorrhage-related deaths in this population occur rapidly, underscoring the need for timely and aggressive interventions.
Objectives:
The purpose of our study was to describe children with life-threatening bleeding.
Design:
We conducted a prospective observational study of children with life-threatening bleeding events.
Setting:
Twenty-four childrens hospitals in the United States, Canada, and Italy participated.
Subjects:
Children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under massive transfusion protocol were included.
Interventions:
Children were compared according bleeding etiology: trauma, operative, or medical.
Measurements And Main Results:
Patient characteristics, therapies administered, and clinical outcomes were analyzed. Among 449 enrolled children, 55.0% were male, and the median age was 7.3 years. Bleeding etiology was 46.1% trauma, 34.1% operative, and 19.8% medical. Prior to the life-threatening bleeding event, most had age-adjusted hypotension (61.2%), and 25% were hypothermic. Children with medical bleeding had higher median Pediatric Risk of Mortality scores (18) compared with children with trauma (11) and operative bleeding (12). Median Glasgow Coma Scale scores were lower for children with trauma (3) compared with operative (14) or medical bleeding (10.5). Median time from bleeding onset to first transfusion was 8 minutes for RBCs, 34 minutes for plasma, and 42 minutes for platelets. Postevent acute respiratory distress syndrome (20.3%) and acute kidney injury (18.5%) were common. Twenty-eight-day mortality was 37.5% and higher among children with medical bleeding (65.2%) compared with trauma (36.1%) and operative (23.8%). There were 82 hemorrhage deaths; 65.8% occurred by 6 hours and 86.5% by 24 hours.
Conclusions:
Patient characteristics and outcomes among children with life-threatening bleeding varied by cause of bleeding. Mortality was high, and death from hemorrhage in this population occurred rapidly.
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