Related Experiment Video
Updated: Jun 15, 2026
A New Hybrid Quantitative Evaluation Model for Axillary Junctional Hemorrhage in Swine
Published on: December 6, 2024
Canadian tertiary care pediatric massive hemorrhage protocols: a survey and comprehensive national review
Valérie Arsenault1,2, Lani Lieberman3,4, Pegah Akbari5
1Division of Transfusion Medicine, Department of Laboratory Medicine, University of Montreal, Montreal, QC, Canada.
Insights
Canadian hospitals show variable adoption of massive hemorrhage protocols (MHPs) for pediatric patients. Standardizing pediatric massive hemorrhage definitions and activation tools is crucial for improving care.
Area of Science:
- Pediatric critical care medicine
- Trauma surgery
- Transfusion medicine
Background:
- Massive hemorrhage protocols (MHPs) improve outcomes in adult trauma and surgery.
- Pediatric massive hemorrhage is a leading cause of death in trauma and cardiac arrest.
- Little is known about the adoption and characteristics of pediatric MHPs in Canada.
Purpose of the Study:
- To investigate the adoption and characteristics of pediatric-specific massive hemorrhage protocols (MHPs) in Canadian tertiary care hospitals.
- To identify variations in MHP content, activation criteria, and components used in pediatric settings.
Main Methods:
- A nationwide survey of Canadian pediatric tertiary care hospitals was conducted.
- Data on MHP activations, content, and associated tools were collected from transfusion medicine directors.
- Pediatric-specific MHP policies were analyzed based on predefined domains.
Main Results:
- 13 out of 18 hospitals had pediatric-specific MHP content, with significant variability.
- Trauma was the most common MHP activation indication (54%).
- Protocols showed inconsistencies in initial component content and emphasis on balanced red blood cell, plasma, and platelet ratios.
Conclusions:
- There is significant variability in pediatric massive hemorrhage protocols across Canadian hospitals.
- A consensus definition for pediatric massive hemorrhage and validated activation tools are needed.
- Prospective assessment of blood component ratios and a national repository are recommended for quality improvement.
Purpose:
Hemorrhage is the leading cause of pediatric death in trauma and cardiac arrest during surgery. Adult studies report improved patient outcomes using massive hemorrhage protocols (MHPs). Little is known about pediatric MHP adoption in Canada.
Methods:
After waived research ethics approval, we conducted a survey of Canadian pediatric tertiary care hospitals to study MHP activations. Transfusion medicine directors provided hospital/patient demographic and MHP activation data. The authors extracted pediatric-specific MHP data from requested policy/procedure documents according to seven predefined MHP domains based on the literature. We also surveyed educational and audit tools. The analysis only included MHPs with pediatric-specific content.
Results:
The survey included 18 sites (100% response rate). Only 13/18 hospitals had pediatric-specific MHP content: eight were dedicated pediatric hospitals, two were combined pediatric/obstetrical hospitals, and three were combined pediatric/adult hospitals. Trauma was the most common indication for MHP activation (54%), typically based on a specific blood volume anticipated/transfused over time (10/13 sites). Transport container content was variable. Plasma and platelets were usually not in the first container. There was little emphasis on balanced plasma/platelet to red-blood-cell ratios, and most sites (12/13) rapidly incorporated laboratory-guided goal-directed transfusion. Transfusion thresholds were consistent with recent guidelines. All protocols used tranexamic acid and eight sites used an audit tool.
Discussion/Conclusion:
Pediatric MHP content was highly variable. Activation demographics suggest underuse in nontrauma settings. Our findings highlight the need for a consensus definition for pediatric massive hemorrhage, a validated pediatric MHP activation tool, and prospective assessment of blood component ratios. A national pediatric MHP activation repository would allow for quality improvement metrics.
