nach oben

European Journal of Trauma and Emergency Surgery

Erschienen in:

14.08.2020 | Original Article

Comparing unbalanced and balanced ratios of blood products in massive transfusion to pediatric trauma patients: effects on mortality and outcomes

verfasst von: Manmeet Sehdev, Areg Grigorian, Catherine Kuza, Matthew Dolich, Boris Borazjani, Michael Lekawa, Jeffry Nahmias

Erschienen in: European Journal of Trauma and Emergency Surgery | Ausgabe 1/2022

Einloggen, um Zugang zu erhalten

Abstract

Background

The utilization and impact of various ratios of transfusions for pediatric trauma patients (PTPs) receiving a massive transfusion (MT) are unknown. Therefore, we sought to determine the risk for mortality in PTPs receiving an MT of ≥ 6 units of packed red blood cells (PRBC) within 24 h. We compared PRBC: plasma ratio of > 2:1 (Unbalanced Ratios, UR) versus ≤ 2:1 (Balanced Ratios, BR), hypothesizing decreased risk of mortality with BR.

Methods

The Trauma Quality Improvement Program was queried (2014–2016) for PTPs receiving a MT. A multivariable logistic regression model was used to determine risk of mortality.

Results

From 239 PTPs receiving an MT, 98 (41%) received an UR, whereas 141 (59%) received a BR. The median ratios, respectively, were 2.7:1 and 1.2:1. Compared to BR patients, UR patients had no differences in injury severity score (ISS), hypotension on admission, and intensive care unit stay (all p > 0.05). The mortality rates for BR and UR were similar (46.1% vs. 52.0%, p = 0.366). Controlling for age, ISS, and severe head injury, UR demonstrated similar risk of mortality compared to BR (p = 0.276). Additionally, ≥ 4:1 ratio versus ≤ 2:1 showed no difference in associated risk of mortality (p = 0.489).

Conclusion

In contrast to adult studies, this study demonstrated that MT ratios of > 2:1 and even ≥ 4:1 were associated with similar mortality compared to BR for PTPs. These results suggest pediatric MT resuscitation may not require strict BR as has been shown beneficial in adult trauma patients. Future prospective studies are needed to evaluate the optimal ratio for PTP MT resuscitation.

Level of evidence

III; Retrospective Care Management Study.

Borse NN, Gilchrist J, Dellinger AM, Rudd RA, Ballesteros MF, Sleet DA. CDC Childhood Injury Report: Patterns of Unintentional Injuries among 0–19 Year Olds in the United States, 2000–2006. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2008.

Hendrickson JE, Shaz BH, Pereira G, Atkins E, Johnson KK, Bao G, Easley KA, Josephson CD. Coagulopathy is prevalent and associated with adverse outcomes in transfused pediatric trauma patients. J Pediatr. 2012;160:204e–9e3.CrossRef

Patregnani JT, Borgman MA, Maegele M, Wade CE, Blackbourne LH, Spinella PC. Coagulopathy and shock on admission is associated with mortality for children with traumatic injuries at combat support hospitals. Pediatr Crit Care Med. 2011;3:273–7.

Christiaans S, Duhacheck-Stapelman A, Russell R, Lisco SJ, Kerby JD, Pittet JF. Coagulopathy after severe pediatric trauma: A review. Shock. 2014;41(6):476–90.CrossRefPubMedPubMedCentral

Livingston MH, Singh S, Merritt NH. Massive transfusion in paediatric and adolescent trauma patients: incidence, patient profile, and outcomes prior to a massive transfusion protocol. Injury Int J. Cared Injured. 2014;45:1301–6.CrossRef

Blain S, Paterson N. Pediatric massive transfusion. BJA Educ. 2015;16(8):269–75.CrossRef

Shroyer MC, Griffin RL, Mortellaro VE, Russell TR. Massive transfusion in pediatric trauma: analysis of the National Trauma Databank. J Surg Res. 2017;208:166–72.CrossRefPubMed

Hwu R, Spinella P, Keller MS, Baker D, Wallendorf M, Leonard JC. The effect of massive transfusion protocol implementation on pediatric trauma care. Transfusion. 2016;56(56):2712–9.CrossRefPubMedPubMedCentral

Horst J, Leonard JC, Vogel A, Jacobs R, Spinella PC. A survey of US and Canadian hospitals' paediatric massive transfusion protocol policies. Transfus Med. 2016;26(1):49–56.CrossRefPubMed

10.

Chidester SJ, Williams N, Wang W, Groner JI. A pediatric massive transfusion protocol. J Trauma Acute Care Surg. 2012;73:1273–7.CrossRefPubMed

11.

Diab Y, Wong E, Luban N. Massive transfusion in children and neonates. Br J Haematol. 2013;161:15–26.CrossRefPubMed

12.

Kamyszek RW, Leraas HJ, Reed C, Ray CM, Nag UP, Poisson JL, Tracy ET. Massive transfusion in the pediatric population: A systemic review and summary of best-evidence practice strategies. J Trauma Acute Care Surg 2019. 86(4)

13.

Dehmer JJ, Adamson WT. Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg. 2010;19:286–91.CrossRefPubMed

14.

Neff LP, Cannon JW, Morrison JJ, Edwards MJ, Spinella PC, Borgman MA. Clearly defining pediatric massive transfusion: cutting through the fog and friction with combat data. J Trauma Acute Care Surg. 2015;78(1):22–8.CrossRefPubMed

15.

Drucker NA, Wang SK, Newton C. Pediatric trauma-related coagulopathy: balanced resuscitation, goal-directed therapy and viscoelastic assays. Semin Pediatr Surg. 2019;28:61–6.CrossRefPubMed

16.

Holcomb JB, Tiley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, del Junco DJ, Brasel JK, Vulger EM, Callcut RA, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma. JAMA. 2015;313(5):471–82.CrossRefPubMedPubMedCentral

17.

Holcomb JB, del Junco DJ, Fox EE, Wade CE, Cohen MJ, Schreiber MA, Alarcon LH, Bai Y, Brasel KJ, Bulger EM, et al. The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013;148:127–36.CrossRefPubMedPubMedCentral

18.

Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, Sabesta J, Jenkins D, Wade CE, Holcomb JB. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007;63:805–13.PubMed

19.

Spinella P, Wade C, Blackbourne LH, Borgman MA, Zarzabal LA, Du F, Perkins JG, Maegele M, Schreiber M, Hess JR, et al. The association of blood component use ratios with the survival of massively transfused trauma patients with and without severe brain injury. J Trauma. 2011;71:S343–S352352.PubMed

20.

Nunns G, Moore E, Stettler GR, Moore HB, Ghasabyan A, Cohen M, Huebner BR, Sillman CC, Banerjee A, Sauaia A. Empiric transfusion strategies during life-threatening hemorrhage. Surgery. 2018;164:306–11.CrossRefPubMed

21.

Wang CH, Hsieh WH, Chou HC, Huang YS, Shen JH, Yeo YH, Chang HE, Chen SC, Lee CC. Liberal versus restricted fluid resuscitation strategies in trauma patients: a systemic review and meta-analysis of randomized control trials and observational studies. Crit Care Med. 2014;42(4):954–61.CrossRefPubMed

22.

Nosanov L, Inaba K, Okoye O, Resnick S, Upperman J, Shulman I, Rhee P, Demetriades D. The impact of blood product ratios in massively transfused pediatric trauma patients. Am J Surg. 2013;206:655–60.CrossRefPubMed

23.

Hwu RS, Keller MS, Spinella PC, Baker D, Tao Y, Leonard JC. Potential effects of high plasma to red blood cell ratio transfusion in pediatric trauma. Trauma. 2017;19(1):21–7.CrossRef

24.

Hendrickson JE, Shaz BH, Pereira G, Parker PM, Jessup P, Atwell F, Polstra B, Atkins E, Johnson KK, Bao G, Easley KA, Josephson CD. Implementation of a pediatric trauma massive transfusion protocol: one institution’s experience. Transfusion. 2012;52:1228–366.CrossRefPubMed

25.

Cannon JW, Johnson MA, Caskey RC, Borgman MA, Neff LP. High ratio plasma resuscitation does not improve survival in pediatric trauma patients. J Trauma Acute Care Surg. 2017;83(2):211–7.CrossRefPubMed

26.

Edwards MJ, Lustik MB, Clark ME, Creamer KM, Tuggle D. The effects of balanced blood component resuscitation and crystalloid administration in pediatric trauma patients requiring transfusion in Afghanistan and Iraq 2002 to 2012. J Trauma Acute Care Surg. 2015;78:330–5.CrossRefPubMed

27.

Cunningham E, Rosenfeld E, Zhu H, Naik-Mathuria BJ, Russel RT, Vogel AM. A high ratio of plasma:pRBC improves survival in massively transfused injured children. J Surg Res 2019(233)13e220

28.

Butler EK, Mills BM, Arbabi S, Bulger EM, Vavilala MS, Groner JI, Stansbury LG, Hess JR, Rivara FP. Association of blood component ratios with 24-hour mortality in injured children receiving massive transfusion. Pediatric Critical Care. 2019;47(7):975–83.

29.

Noland DK, Apelt N, Greenwell C, Tweed J, Notrica DM, Garcia NM, Maxson RT, Eubanks JW III, Alder AC. Massive transfusion in pediatric trauma: ATOMAC perspective. J Pediatr Surg. 2019;54:345–9.CrossRefPubMed

30.

Karam O, Tucci M. Massive transfusion in children. Transfus Med Rev. 2016;30:213–6.CrossRefPubMed

31.

Maw G, Furyk C. Pediatric massive transfusion a systemic review. Pediatr Emer Care. 2018;34:594–8.CrossRef

32.

Nystrup K, Stensballe BM, Johansson PI, Ostrowski SR. Transfusion therapy in paediatric trauma patients: a review of the literature. Scand J Trauma Resusc Emerg Med. 2015;23:21.CrossRefPubMedPubMedCentral

33.

Gonzalez E, Moore EE, Moore HB, Chapman MP, Chin TL, Ghasabyan A, Wohlauer MV, Barnett CC, Bensard DD, Biffl WL, et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays. Ann Surg. 2006;263(6):1051–9.CrossRef

34.

Kuhle S, Male C, Mitchell L. Developmental hemostasis: pro- and anticoagulant systems during childhood. Semin Thromb Hemost. 2003;29(4):329–38. https://doi.org/10.1055/s-2003-42584.CrossRefPubMed

35.

Ozturk H, Dokucu AI, Onen A, Otçu S, Gedik S, Azal OF. Non-operative management of isolated solid organ injuries due to blunt abdominal trauma in children: a fifteen-year experience. Eur J Pediatr Surg. 2004;14(1):29–34. https://doi.org/10.1055/s-2004-815777.CrossRefPubMed

36.

Daodu O, Brindle M, Alvarez-Allende CR, Lockyer L, Weber B, Lopushinsky SR. Outcomes of an accelerated care pathway for pediatric blunt solid organ injuries in a public healthcare system. J Pediatr Surg. 2017;52(5):826–31. https://doi.org/10.1016/j.jpedsurg.2017.01.037.CrossRefPubMed

Titel: Comparing unbalanced and balanced ratios of blood products in massive transfusion to pediatric trauma patients: effects on mortality and outcomes
verfasst von: Manmeet Sehdev
Areg Grigorian
Catherine Kuza
Matthew Dolich
Boris Borazjani
Michael Lekawa
Jeffry Nahmias
Publikationsdatum: 14.08.2020
Verlag: Springer Berlin Heidelberg
Erschienen in: European Journal of Trauma and Emergency Surgery / Ausgabe 1/2022
Print ISSN: 1863-9933
Elektronische ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-020-01461-7

Update Orthopädie und Unfallchirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Live-Webinar "Urologie und Sexualmedizin in der Praxis"

Springer Medizin

Comparing unbalanced and balanced ratios of blood products in massive transfusion to pediatric trauma patients: effects on mortality and outcomes