J. D. Kauffman1, C. N. Litz1, S. A. Thiel1, L. K. Bingham2, P. D. Danielson1, N. M. Chandler1 1Johns Hopkins All Children’s Hospital,Division Of Pediatric Surgery,St. Petersburg, FLORIDA, USA 2Johns Hopkins All Children’s Hospital,Division Of Critical Care Medicine,St. Petersburg, FLORIDA, USA
Introduction: Massive transfusion protocols (MTP) have been shown to improve survival, decrease morbidity, and reduce unnecessary blood product use in adults. Studies comparing outcomes of pediatric cohorts before and after implementation of MTP have failed to demonstrate either a survival benefit or decrease in blood product utilization following MTP implementation. More studies are needed to clarify the utility of pediatric MTP and elucidate how it can be optimized in this population. The purpose of this study is to review our institutional experience with MTP since it was initiated in 2012.
Methods: The institutional MTP registry and electronic medical records were retrospectively reviewed to identify all patients for whom MTP was initiated between January 1, 2012 and June 30, 2017. Data obtained included patient demographics, indication for transfusion, laboratory results, volume of blood products transfused (in ml/kg), and amount of blood products wasted. Outcomes such as intensive care unit (ICU) length of stay, duration of intubation, and mortality were assessed. MTP parameters, including time to initial transfusion, duration of MTP activation, and protocol documentation were also evaluated. Ordinal data was analyzed using Fisher’s exact test. Continuous data with dichotomous outcome variables was analyzed with multiple logistic regression. Statistical significance was set at p<0.05.
Results: Sixteen subjects were identified, two of which underwent MTP twice, for a total of 18 MTP activations over 5.5 years. The mean age was 11.8 years; 56% were male. The majority of activations occurred in either the ICU or operating room; the remaining two (11%) occurred in the emergency department. Five (31%) of those undergoing MTP were trauma patients. Overall mortality was 50%, whereas mortality among the trauma subgroup was only 20% (p=0.28). The mean time to transfusion following initiation of the protocol was 39 minutes (range 0 – 109 minutes); mean duration of activation was 78 minutes (range 13 – 232 minutes). The mean red blood cell/plasma/platelet transfusion ratio was more balanced following MTP initiation than prior to MTP activation (6:3:1 vs. 8:1:1). On multiple logistic regression there was no significant difference in mortality when considering age, weight, total volume of products transfused, volume infused in the first 24 hours, or relative ratio of products infused. Initial laboratory hemoglobin, platelet, and INR levels at time of MTP initiation likewise had no bearing on mortality.
Conclusion: Activation of the massive transfusion protocol at our institution is a rare event and is associated with 50% mortality. Those for whom MTP was initiated at our institution received more balanced proportions of blood products following the initiation of MTP. Larger prospective studies are warranted to determine the factors related to survival of pediatric patients requiring massive transfusion of blood products.