E. H. Rosenfeld1, M. E. Cunningham1, P. Lau1, A. Karediya1, B. Naik-Mathuria1, R. T. Russell2, A. M. Vogel1 1Baylor College Of Medicine And Texas Childrens Hospital,DeBakey Department Of Surgery,Houston, TX, USA 2Children’s Hospital Of Alabama,Department Of Pediatric Surgery,Birmngham, AL, USA
Introduction:
Massive transfusion protocols (MTP) have been widely implemented and have been shown to reduce mortality in adults. However, for children with traumatic brain injuries (TBI), the definition of massive transfusion is unclear as previous studies have excluded this population. The purpose of this study is to identify an optimal definition of MTP in pediatric trauma patients with TBI.
Methods:
Severely injured children (age ≤18 years, injury severity score ≥25) with severe traumatic brain injury in the Trauma Quality Improvement Program research datasets 2015 and 2016 that received blood products were identified. Severe TBI was defined as those with a head abbreviated injury scale score of 3-5. Children with burns and unsurvivable injuries were excluded. Patient demographics, injury patterns, procedures, and outcomes were collected and analyzed using descriptive statistics, Wilcoxon Rank-Sum, Chi-Square and logistic regression. Total blood product volumes (red cells, platelets, plasma and cryoprecipitate) were weight adjusted. Continuous variables are presented as median [IQR]. Sensitivity and specificity curves for in-hospital and 24-hour mortality were used to identify an optimal MTP threshold.
Results:
Of the 460 included children, the mortality rate was 43%. There were no differences in age, gender, race, heart rate at presentation, or ISS between children that lived or died. However, those who died had lower Glasgow Coma Scores (3 [3,8] vs 3 [3,3]; p<0.01), were more likely to have had a penetrating injury (20% vs 11%; p<0.01) and were more likely to be hypotensive for age (62% vs 34%; p<0.01). Total blood products infused were greater in those who died (48 ml/kg/24-hours [20,97] vs 34 [18,61]; p<0.01). Increasing total blood transfusion volume (OR 1.005; 95% CI 1.001-1.009; p=0.02) and hypotension (OR 2.2; 95% CI 1.3-3.7; p<0.01) were associated with in-hospital mortality. Only hypotension (OR 3.4; 95% CI 1.7-6.5; p<0.01) was associated with 24-hour mortality. Sensitivity & specificity for both in-hospital and 24-mortality was optimized at 38 ml/kg/24 (figure 1). This cutoff was independently associated with in-hospital but not 24-hour mortality (OR 1.9; 95% CI 1.1-3.1; p=0.02) and (1.24; 95% CI 0.7-2.3; p=0.50).
Conclusion:
For children with TBI the optimal definition of MTP threshold is 38 mL/kg/24-hours of total administered blood products. This threshold predicts in-hospital mortality. Although prospective validating studies are needed, this threshold may be used to improve research methodology, mortality, and resource utilization.
