1.
Massive Transfusion Protocols in Pediatric Trauma Population: A Systematic Review
Kinslow K, McKenney M, Boneva D, Elkbuli A
Transfus Med. 2020
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Editor's Choice
Abstract
BACKGROUND Our main objective was to review the literature to answer the following questions regarding pediatric massive transfusion (PMT) protocols: 1) How is PMT defined? 2) Which blood product ratios have been investigated and what is their effect on outcomes? 3) What evidence exists regarding PMT outcomes? METHODS The PRISMA guidelines were used. We searched PubMed, Google Scholar, Cochrane Library, EMBASE, Wiley Online Library, and Ovid. Articles were screened for inclusion based on relevance to PMT. Articles were assessed for study design, presence of established/tested PMT, PMT definition, PMT activation criteria, and Transfusion Ratios, for final determination of article inclusion. RESULTS Our search produced 3213 articles with 33 included for final review. Existing definitions of PMT are based on volume administered/kg but vary in timeframe criteria (over 4 hr vs 24 hr). Some studies have investigated "high" balanced transfusion ratios as seen in adults (1:1 FFP:pRBC) with a few showing statistically significant improvement in pediatric mortality vs lower ratios. PMT protocol implementation has not been shown to consistently reduce pediatric trauma mortality across multiple centers. However, other operational aspects such as reduced time to first transfusion are apparent benefits. CONCLUSIONS There is poor consensus over the definition of PMT. Definitions that involve early recognition have the most promise for practice and future studies. Evidence supporting an optimal blood product ratio in PMT is also lacking but trends towards supporting balanced approaches. Implementation of PMT protocols have been limited in showing significant improvement of overall pediatric trauma mortality but may reduce associated morbidity.
PICO Summary
Population
Paediatric trauma patients undergoing massive transfusions (33 studies).
Intervention
Systematic review to define paediatric massive transfusion (PMT) protocols, and to review the evidence on PMT outcomes.
Comparison
Outcome
Existing definitions of PMT are based on volume administered/kg but vary in timeframe criteria (over 4 hr vs. 24 hr). Some studies have investigated "high" balanced transfusion ratios as seen in adults (1:1 FFP:pRBC) with a few showing statistically significant improvement in paediatric mortality vs. lower ratios. PMT protocol implementation has not been shown to consistently reduce paediatric trauma mortality across multiple centers. However, other operational aspects such as reduced time to first transfusion are apparent benefits.
2.
Pediatric blunt renal trauma practice management guidelines: Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society
Hagedorn JC, Fox N, Ellison JS, Russell R, Witt CE, Zeller K, Ferrada P, Draus JM Jr
The Journal of Trauma and Acute Care Surgery. 2019;86(5):916-925
Abstract
BACKGROUND Injury to the kidney from either blunt or penetrating trauma is the most common urinary tract injury. Children are at higher risk of renal injury from blunt trauma than adults, but no pediatric renal trauma guidelines have been established. The authors reviewed the literature to guide clinicians in the appropriate methods of management of pediatric renal trauma. METHODS Grading of Recommendations Assessment, Development and Evaluation methodology was used to aid with the development of these evidence-based practice management guidelines. A systematic review of the literature including citations published between 1990 and 2016 was performed. Fifty-one articles were used to inform the statements presented in the guidelines. When possible, a meta-analysis with forest plots was created, and the evidence was graded. RESULTS When comparing nonoperative management versus operative management in hemodynamically stable pediatric patient with blunt renal trauma, evidence suggests that there is a reduced rate of renal loss and blood transfusion in patients managed nonoperatively. We found that in pediatric patients with high-grade American Association for the Surgery of Trauma grade III-V (AAST III-V) renal injuries and ongoing bleeding or delayed bleeding, angioembolization has a decreased rate of renal loss compared with surgical intervention. We found the rate of posttraumatic renal hypertension to be 4.2%. CONCLUSION Based on the completed meta-analyses and Grading of Recommendations Assessment, Development and Evaluation profile, we are making the following recommendations: (1) In pediatric patients with blunt renal trauma of all grades, we strongly recommend nonoperative management versus operative management in hemodynamically stable patients. (2) In hemodynamically stable pediatric patients with high-grade (AAST grade III-V) renal injuries, we strongly recommend angioembolization versus surgical intervention for ongoing or delayed bleeding. (3) In pediatric patients with renal trauma, we strongly recommend routine blood pressure checks to diagnose hypertension. This review of the literature reveals limitations and the need for additional research on diagnosis and management of pediatric renal trauma. LEVEL OF EVIDENCE Guidelines study, level III.