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Massive Transfusion Protocol

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Submitted by: C. Perlick RN, BSN

Overview: Massive transfusion protocol is used readily in the adult population with some clearly defined activation criteria such as Assessment of Blood Consumption (ABC) Score. While trauma is the leading cause of death in children >1 year of age, hemorrhage is t he most common cause of preventable death.A consistent activation point has not yet been defined in children.

Why are these articles are relevant? A literature review shows that there is insufficient data and protocols published on MTP in children. The A AST 2014 PLENARY PAPER concluded that a threshold of 40 mL/kg of all blood products given at any time in the first 24 hours reliably identifies critically injured children at high risk for early and in - hospital death. The trigger point for MTP activation s eems to be clinician - based due to the lack of sufficient studies. All authors cited conclude that MTP in the pediatric population is an area in need of further study.

J. Horst,1 J. C. Leonard,2 A. Vogel,3 R. Jacobs4 &P. C. Spinella4 A survey of US and Canadian hospitals ’ paediatric massive transfusion protocol policies Transfusion Medicine , 2016, 26, 49 – 56

Background: Trauma is the leading cause of death in children > 1 year of age, with hemorrhage as the most common cause of med ically preventable death. While massive transfusion protocols (MTPs) have been investigated and used in adults to reduce death from hemorrhage, there are a paucity of published data on MTP practices and outcomes in children. This study aimed to survey cur rent MTP policies and the frequency of activation at paediatric care centres.

Study design and methods: We conducted a survey of MTPs at hospitals in the United States and Canada, including children’s general hospitals, children’s specialty hospitals and children’s units in general hospitals. We collected information on how the MTP is activated, what therapeutics are given, frequency of its use, and how it is audited for compliance.

Results: Forty - six survey responses were analysed. Physician discretion w as the most common activation criteria (89%). A majority of sites (78%) targeted a ‘high’ (?1 : 2) ratio of plasma to red blood cells (RBC). Fifteen percent of sites use antifibrinolytics in their MTPs. Eighty nine percent of sites have type - O RBCunits and 48%of sites had thawed plasma units stored in an immediately available location.

Conclusion: There is a wide variation in MTPs among paediatric hospitals with regard to both activation criteria and products administered. This underscores the need for future prospective studies to determine the most effective resuscitation methods for paediatric populations to improve outcomes and therapeutic safety for massive bleeding.

Shannon N. Acker1 Brianne Hall2 Lauren Hill2 David A. Partrick2 Denis D. Bensard3 Adult - Based Massive Transfusion Protocol Activation Criteria Do Not Work in Children European Journal of Pediatric Surgery Vol. 27 No. 1/2017

Abstract: Introduction In the adult population, assessment of blood consumption (ABC) score [penetrating mechanism, positive focused assessment sonography for trauma (FAST), systolic blood pressure < 90, and heart rate (HR) > 120] > 2 identifies trauma patients who r equire massive transfusion (MT) with sensitivity and specificity of 75 and 86%. We hypothesized that the adult criteria cannot be applied to children, as the vital sign cutoffs are not age - adjusted. We aimed to determine if the use of a shock index, pediat ric age - adjusted (SIPA) would improve the discriminate ability of the ABC score in children.

Materials and Methods A retrospective review of children age 4 to 15 who received a packed red blood cell (PRBC) transfusion during admission for trauma between 2 008 and 2014 was performed. We compared the sensitivity and specificity of ABC score > 2, elevated SIPA, and age - adjusted ABC score (ABC - S) utilizing SIPA in place of HR and BP, to determine the need for MT.

Results A total of 50 children were included, 31 received PRBC transfusion within 6 hours of injury, 7 children had a positive FAST, and 3 suffered penetrating trauma, all in the early transfusion group. ABC score > 2 is 29% sensitive and 100% specific at predicting need for MT while ABC - S score > 1 is 65% sensitive and 84% specific.

Conclusions Adult - based criteria for activation of MT perform poorly in the pediatric population. The use of SIPA modestly improves the sensitivity of the ABC score in children; however, the sensitivity and specificity of this score are still worse than when used in an adult population. This suggests the need to develop a new score that takes into account the low rate of penetrating trauma and positive FAST in the pediatric population.

AAST 2014 PLENARY PAPER Lucas P. Ne ff, MD, Jeremy W. Cannon, MD, Jonathan J. Morrison, MRCS, Mary J. Edwards, MD, Philip C. Spinella, MD, and Matthew A. Borgman, MD, San Antonio, Texas Clearly defining pediatric massive transfusion: Cutting through the fog and friction with combat data ( J Trauma Acute Care Surg . 2015;78: 22 Y 29. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.)

BACKGROUND: Massive transfusion (MT) in pediatric patients remains poorly defined. Using the largest existing registry of transfused pediatric trau ma patients, we sought a data - driven MT threshold.

METHODS: The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric trauma patients (G18 years). Burns, drowning, isolated head injury, and missing Injury Severity Score (ISS) w ere excluded. MTwas evaluated as a weight - based volume of all blood products transfused in the first 24 hours. Mortality at 24 hours and in the hospital was calculated for increasing transfusion volumes. Sensitivity and specificity curves for predicting mo rtality were used to identify an optimal MT threshold. Patients above and below this threshold (MT+ and MTj, respectively) were compared.

RESULTS: The Department of Defense Trauma Registry yielded 4,990 combat - injured pediatric trauma patients, of whom 1, 113 were transfused and constituted the study cohort. Sensitivity and specificity for 24 - hour and in - hospital mortality were optimal at 40.1 - mL/kg and 38.6 - mL/kg total blood products in the first 24 hours, respectively.With the use of a pragmatic threshold of 40 mL/kg, patients were divided intoMT+ (n = 443) and MTj(n = 670).MT+ patients were more often in shock (68.1% vs. 47.0%, p G 0.001), hypothermic (13.0% vs. 3.4%, p G 0.001), coagulopathic (45.0% vs. 29.6%, p G 0.001), and thrombocytopenic (10.6% vs. 5.0%, p = 0.002) on presentation. MT+ patients had a higher ISS, more mechanical ventilator days, and longer intensive care unit and hospital stay. MT+ was independently associated with an increased 24 - hour mortality (odds ratio, 2.50; 95% confidence inter val, 1.28Y4.88; p = 0.007) and in - hospital mortality (odds ratio, 2.58; 95% confidence interval, 1.70Y3.92; p G 0.001).

CONCLUSION: Based on this large cohort of transfused combat - injured pediatric patients, a threshold of 40 mL/kg of all blood products g iven at any time in the first 24 hours reliably identifies critically injured children at high risk for early and in - hospital death. This evidence - based definition will provide a consistent framework for future research and protocol development in pediatri c resuscitation. (J Trauma Acute Care Surg. 2015;78: 22Y29. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.)

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