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Recognizing life-threatening bleeding in pediatric trauma: A standard for when to activate massive transfusion
Katrina M Morgan1, Barbara A Gaines, Ward M Richardson
1From the Department of General Surgery (K.M.M.), Department of General Surgery, Division of General and Trauma Surgery (C.M.L.), and Department of General Surgery, Division of Pediatric General and Thoracic Surgery (B.A.G., W.M.R., S.S.), and University of Pittsburgh Medical Center Presbyterian, Pittsburgh, Pennsylvania.
Insights
A threshold of >20 mL/kg of blood products within one hour can identify children at high risk of mortality from traumatic hemorrhage. This critical administration threshold (CAT) helps activate massive transfusion protocols for timely, aggressive resuscitation in pediatric trauma patients.
Area of Science:
- Pediatric Trauma Care
- Hemorrhagic Shock Management
- Massive Transfusion Protocols
Background:
- Traumatic hemorrhage is a leading cause of preventable death in pediatric trauma.
- Early identification of life-threatening hemorrhage in children is challenging.
- No established clinical critical administration threshold (CAT) exists for pediatric massive transfusion protocols.
Purpose of the Study:
- To establish a clinical critical administration threshold (CAT) for activating massive transfusion protocols in pediatric trauma patients.
- To identify a specific volume of blood products transfused within an hour that predicts adverse outcomes in children.
Main Methods:
- Retrospective analysis of pediatric trauma patients (0-17 years) who received transfusions within 24 hours (2010-2019).
- Calculated greatest volume of weight-adjusted blood products transfused within 1 hour.
- Determined optimal cutoff using Youden's index to predict mortality, urgent surgery, and re-bleeding.
Main Results:
- The optimal CAT was identified as >20 mL/kg of blood products within 1 hour.
- This threshold predicted in-hospital mortality with 70% sensitivity and 77% specificity.
- Patients meeting the CAT had 3.4 times increased odds of mortality and a 10% increased risk per unit transfused.
Conclusions:
- A threshold of >20 mL/kg of any blood product within an hour should trigger massive transfusion protocols in children.
- Pediatric patients meeting this CAT are at high risk for mortality and require interventions.
- Targeted, timely, and aggressive hemostatic resuscitation is recommended for pediatric CAT+ patients.
Background:
Traumatic hemorrhage is the most common cause of preventable death in civilian and military trauma. Early identification of pediatric life-threatening hemorrhage is challenging. There is no accepted clinical critical administration threshold (CAT) in children for activating massive transfusion protocols.
Methods:
Children 0 to 17 years old who received any transfusion in the first 24 hours after injury between 2010 and 2019 were included. The type, volume, and time of administration for each product were recorded. The greatest volume of weight-adjusted products transfused within 1 hour was calculated. The cut point for the number of products that maximized sensitivity and specificity to predict in-hospital mortality, need for urgent surgery, and second life-threatening bleeding episode was determined using Youden's index. A binary variable (CAT+) was generated using this threshold for inclusion in a multivariable logistic regression model.
Results:
In total, 287 patients were included. The median (interquartile range) age was 6 (2-14) years, 60% were males, 83% sustained blunt trauma, and the median (interquartile range) Injury Severity Score was 26 (17-35). The optimal cutoff to define CAT+ was >20 mL/kg of product; this optimized test characteristics for mortality (sensitivity, 70%; specificity, 77%), need for urgent hemorrhage control procedure (sensitivity, 65%; specificity, 74%). and second bleeding episode (sensitivity, 77%; specificity, 74%). There were 93 children (32%) who were CAT+. On multivariate regression, being CAT+ was associated with 3.4 increased odds of mortality (95% confidence interval, 1.67-6.89; p = 0.001) after controlling for age, hypotension, Injury Severity Score, and Glasgow Coma Scale. For every unit of product administered, there was a 10% increased risk of mortality (odds ratio, 1.1; p < 0.001).
Conclusion:
Transfusion of more than 20 mL/kg of any blood product within an hour should be used as a threshold for activating massive transfusion protocols in children. Children who meet this CAT are at high risk of mortality and need for interventions; this population may benefit from targeted, timely, and aggressive hemostatic resuscitation.
Level Of Evidence:
Therapeutic/Care Management; Level III.
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