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Key Indicators Associated With Survival in Pediatric Trauma Massive Transfusion Protocol
Theodore Wang1, Sorasicha Nithikasem1, Thomas Hong1
1Division of Pediatric Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.
Insights
This study identified factors influencing survival in pediatric trauma patients receiving massive transfusion protocols (MTP). Tachycardia and Level I trauma centers were protective, while hypothermia and severe injury indicated poor outcomes.
Area of Science:
- Trauma Surgery
- Pediatric Critical Care
- Transfusion Medicine
Background:
- No established massive transfusion protocol (MTP) scoring system exists for pediatric trauma patients.
- This study evaluated factors associated with survival in pediatric trauma patients undergoing MTP.
Purpose of the Study:
- To identify predictors of survival in pediatric trauma patients requiring MTP.
- To inform the development of optimized MTP strategies for children.
Main Methods:
- Retrospective analysis of the National Trauma Data Bank (2017-2019) for pediatric patients (<18 years) receiving MTP (>40 mL/kg blood products within 4h).
- Exclusion of patients with non-survivable injuries or no signs of life on admission.
- Multivariable regression analysis to determine factors predictive of survival.
Main Results:
- Of 947 pediatric patients requiring MTP, 68% survived.
- Survival was associated with hemorrhage control surgery, tachycardia, and Level I trauma center presentation.
- Poor prognostic factors included hypothermia, severe Glasgow Coma Score (GCS), high Injury Severity Score (ISS), self-payment, and >80 mL/kg transfused blood products.
Conclusions:
- Tachycardia and Level I pediatric trauma centers are protective factors in MTP.
- Hypothermia, severe GCS, severe ISS, self-payment, and excessive blood product transfusion (>80 mL/kg) are associated with decreased survival.
- Development of predictive tools is crucial to guide MTP use and identify patients needing alternative interventions.
Introduction:
Prior studies and scoring systems have been developed to optimize massive transfusion protocol (MTP) in adults, but an established protocol for children does not yet exist. This study aimed to evaluate the factors associated with survival in MTP activation among pediatric trauma patients.
Methods:
Patients aged 18 y and under who received MTP were queried from the National Trauma Data Bank from 2017 to 2019, with MTP defined as receiving >40 mL/kg of blood products (e.g., red blood cells, plasma, and platelets) within 4 h of admission. Patients with fatal injuries and/or no signs of life on admission were excluded. Baseline characteristics and clinical outcomes were compared between patients who were discharged alive (DC-alive) and those who died (DC-deceased). Multivariable regression was performed to identify indicators predictive of survival and expressed in odds ratios (ORs) and 95% confidence intervals (CIs).
Results:
Of 9115 patients who underwent transfusion, 947 (10.4%) required MTP and remained in the cohort. A total of 642 patients (68%) survived. Patients who survived were more likely to undergo hemorrhage control surgery (71% versus 40%, P < 0.001). No predominance of any combination of blood products transfused (e.g., red blood cells, plasma, and platelets) was observed between groups (P = 1.00). Factors associated with survival included tachycardia (OR 2.44, 95% CI 1.60-3.76) and presentation to level I pediatric trauma centers (OR 1.47, 95% CI 0.96-2.27). Poor prognostic factors for survival included hypothermia (OR 0.52, 95% CI 0.32-0.85), severe Glasgow coma score (GCS; OR 0.07, 95% CI 0.04-0.12), very severe injury severity score (ISS; OR 0.38, 95% CI 0.22-0.64), self-payment (OR 0.35, 95% CI 0.19-0.65), and >80 mL per kilogram (mL/kg) of transfused blood products (OR 0.56, 95% CI 0.37-0.85).
Conclusions:
Tachycardia and pediatric-verified trauma centers appear to be protective in pediatric trauma MTP; decreased survival was associated with hypothermia, severe Glasgow coma score, very severe injury severity score, self-payment, and >80 mL/kg of transfused blood products. Prediction tools should identify patients who are most likely to benefit from MTP and alternative interventions for those unlikely to improve with MTP.
