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Use of Antifibrinolytics in Pediatric Life-Threatening Hemorrhage: A Prospective Observational Multicenter Study
Philip C Spinella1, Julie C Leonard2, Barbara A Gaines3
1Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA.
Insights
Antifibrinolytic medications like tranexamic acid significantly reduced mortality in children with life-threatening hemorrhage. Early administration of these drugs improved survival rates in pediatric bleeding emergencies.
Area of Science:
- Pediatric Critical Care Medicine
- Hemorrhagic Shock Management
- Pharmacological Interventions in Trauma
Background:
- Life-threatening hemorrhage is a major cause of mortality in children.
- Antifibrinolytic agents are used to treat bleeding but their impact in pediatric populations requires further investigation.
- Massive transfusion protocols are critical for managing severe bleeding in children.
Purpose of the Study:
- To evaluate the effectiveness of antifibrinolytic medications in reducing mortality among children experiencing life-threatening hemorrhage.
- To assess the association between antifibrinolytic use and survival outcomes in pediatric bleeding events.
Main Methods:
- Secondary analysis of a prospective observational study (MAST-IC) involving children with life-threatening bleeding.
- Comparison of outcomes between children who received antifibrinolytics (tranexamic acid or aminocaproic acid) and those who did not.
- Statistical analysis included Cox proportional hazard and Kaplan-Meier survival analysis, adjusting for key clinical variables.
Main Results:
- Of 449 pediatric patients, 12% received antifibrinolytics.
- The antifibrinolytic group showed significantly lower 6-hour mortality (6% vs. 17%) and 6-hour mortality due to hemorrhage (4% vs. 14%).
- Adjusted analyses revealed that antifibrinolytics were independently associated with decreased 6- and 24-hour mortality (aOR 0.29 and 0.45, respectively).
Conclusions:
- Antifibrinolytic administration in children with life-threatening hemorrhage is independently linked to improved survival.
- These findings support the consideration of antifibrinolytics for pediatric patients experiencing severe bleeding.
- Further research may refine optimal use of antifibrinolytics in pediatric critical care.
Objectives:
To assess the impact of antifibrinolytics in children with life-threatening hemorrhage.
Design:
Secondary analysis of the MAssive Transfusion epidemiology and outcomes In Children study dataset, a prospective observational study of children with life-threatening bleeding events.
Setting:
Twenty-four children's hospitals in the United States, Canada, and Italy.
Patients:
Children 0-17 years old who received greater than 40 mL/kg of total blood products over 6 hours or were transfused under activation of massive transfusion protocol.
Intervention/Exposure:
Children were compared according to receipt of antifibrinolytic medication (tranexamic acid or aminocaproic acid) during the bleeding event.
Measurements And Main Results:
Patient characteristics, medications administered, and clinical outcomes were analyzed using Cox proportional hazard and Kaplan-Meier survival analysis. The primary outcome was 24-hour mortality. Of 449 patients analyzed, median age was 7 years (2-15 yr), and 55% were male. The etiology of bleeding was 46% traumatic, 34% operative, and 20% medical. Twelve percent received antifibrinolytic medication during the bleeding event (n = 54 unique subjects; n = 18 epsilon aminocaproic acid, n = 35 tranexamic acid, and n = 1 both). The antifibrinolytic group was comparable with the nonantifibrinolytic group on baseline demographic and physiologic parameters; the antifibrinolytic group had longer massive transfusion protocol duration, received greater volume blood products, and received factor VII more frequently. In the antifibrinolytic group, there was significantly less 6-hour mortality overall (6% vs 17%; p = 0.04) and less 6-hour mortality due to hemorrhage (4% vs 14%; p = 0.04). After adjusting for age, bleeding etiology, Pediatric Risk of Mortality score, and plasma deficit, the antifibrinolytic group had decreased mortality at 6- and 24-hour postbleed (adjusted odds ratio, 0.29 [95% CI, 0.09-0.93]; p = 0.04 and adjusted odds ratio, 0.45 [95% CI, 0.21-0.98]; p = 0.04, respectively).
Conclusions:
Administration of antifibrinolytic medications during the life-threatening event was independently associated with improved 6- and 24-hour survivals in bleeding children. Consideration should be given to use of antifibrinolytics in pediatric patients with life-threatening hemorrhage.
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