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Massive Transfusion Journal Scan

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Offered by the PTS Education Committee

Journal Scan:
Massive Transfusion

Prepared by: Roberta Miller, DNP RN CPN CPEN TCRN
Cook Children's Medical Center

Article #1:

A High Ratio of Plasma: RBC Improves Survival in Massively Transfused Injured Children

CITATION: Cunningham ME, Rosenfeld EH, Zhu H, Naik-Mathuria BJ, Russell RT, Vogel AM. A High Ratio of Plasma: RBC Improves Survival in Massively Transfused Injured Children. Journal of Surgical Research. 2019;233:213-220. doi:10.1016/j.jss.2018.08.007

HOT TOPIC: Massive Blood Transfusion Protocol in Pediatric Trauma Patients

Authors: Megan E. Cunningham MD, Eric H .Rosenfeld MD, Huirong Zhu PhD, Bindi J. Naik-Mathuria MD, Robert T. Russell MD, MPH, Adam M .Vogel MD
Author Affiliations: Department of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, Department of Pediatric Surgery, Children's of Alabama, Birmingham, Alabama

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WHY THIS ARTICLE IS RELEVANT OR IMPORTANT: Massive transfusion protocols with balanced blood product ratios have been associated with improved outcomes in adult trauma. The impact on pediatric trauma is unclear. Although the overall number of childhood deaths related to trauma is declining, it remains the leading cause of mortality among children. To combat death related to exsanguination, massive transfusion protocols (MTPs) have been set into place. The ratio of blood products given during massive transfusion plays a key role in MTP design. Recent adult studies have shown an increase in early survival, earlier hemostasis, and decreased death from exsanguination when either a high or balanced (1:1:1) ratio of plasma: platelet: red blood cell (RBC) is administered. Similar studies involving pediatric trauma patients have not demonstrated such results.

VERY BRIEF REVIEW: The article describes a retrospective study evaluating outcomes data for pediatric trauma patients receiving

Background: The top mechanisms of traumatic injury include motor vehicle collision, suicide, and homicide. Over the last 3 decades, research has been conducted to further reduce mortality in the acutely injured patient by initiating damage control resuscitation. The principal of damage control resuscitation is to reduce the effects of hypothermia, acidosis, and coagulopathy, known as the "lethal triad of death." Exsanguination, a major contributor to the lethal triad, has been shown to result in mortality 3 to 6 h from hospital admission. To combat death related to exsanguination, massive transfusion protocols (MTPs) have been set into place. These proactive standardized protocols have been well described in the adult literature, but are still in the early stages when it comes to studies and implementation in the pediatric populace.

Methods: A retrospective review was performed using the American College of Surgeons Pediatric Trauma Quality Improvement Program (ACS TQIP-P) data bank. The Baylor College of Medicine Institutional Review Board granted a study review exemption, as no patient identifiers were present in the data bank. Data from January 2015 to December 2016 were analyzed. Data related to demographics, injury, vitals, and outcomes were collected for analysis. Significant demographics included age, gender, and weight. Injury severity score (ISS) (a derivative of the three highest AIS scores), Glasgow coma score (GCS), and mechanisms of injury were all used to describe injury at time of arrival. The pediatric age-adjust shock index was included with standard vital data. Patient outcomes included ventilator, intensive care unit (ICU), and hospital-free days, in-hospital complication rates (acute kidney injury, acute respiratory distress syndrome, severe sepsis, infection, deep venous thrombosis/pulmonary embolism), hemorrhage control procedure rates, and mortality rates. Plasma and platelet ratios were independently evaluated according to the three cohort ratios to reflect the methodology of the PROMMTT trial and other pediatric studies looking at blood product ratio during massive transfusion.

Results: Children who received a high plasma:RBC ratio had improved survival at 4 and 24 h according to Kaplan-Meier curve and log rank analysis. When the curves were extended out to 30 d, survival among the high ratio group remained significant (log rank; P < 0.01). There was no improvement in survival among the platelet:RBC cohorts when performing similar analysis. Logistic regression was performed controlling for age, gender, mechanism of injury, ISS, GCS, RR, pediatric age-adjust shock index, RBC volume, total blood volume, and blood product ratio. Those at risk for mortality had a decreased GCS (AOR 0.85; 95% CI 0.76-0.94; P < 0.01), abnormal respiratory rate (AOR 2.7; 95% CI 1.05-7.14; P = 0.04), and increased RBC transfusion volume (AOR 1.01; 95% CI 1.01-1.02; P < 0.01). Neither plasma nor platelet ratios were independently associated with mortality.

Conclusion: Blood product ratio is an important factor in MTP design. Giving high plasma:RBC ratios during massive transfusion may improve survival in the civilian pediatric trauma population. Larger prospective studies are needed to validate the current literature on the topic.

PTS Summary: Components of massive transfusion protocols lack standardization for pediatric trauma patients. However, limited research exists supporting blood product ratios in the pediatric setting. High plasmsa to RBC ration may improve pediatric trauma patient outcomes. More research is needed in the area of pediatric MTP.

Article #2:

Massive Transfusion Protocols for Pediatric Patients: Current Perspectives

CITATION: Evangelista ME, Gaffley M, Neff LP. Massive Transfusion Protocols for Pediatric Patients: Current Perspectives. Journal of Blood Medicine. 2020;ume 11:163-172

Authors: Evangelista ME, Gaffley M, Neff LP
Author Affiliations: General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA; Pediatric Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA

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WHY THIS ARTICLE IS RELEVANT OR IMPORTANT: In adults, the use of balanced resuscitation and study of massive transfusion protocols have led to improved outcomes for patients and continues to be refined. In children, massive transfusion protocols require further development to assess efficacy. Standardization is needed as transfusions and activation of protocols still rely on physician discretion in most pediatric settings. Further research is required to define the pediatric trauma population that will benefit, when to activate these protocols and how to use adjuncts such as tranexamic acid or factor VII in resuscitation. In addition, future implementation of technology such as hemoglobin-based oxygen carriers to increase survival should be studied further in this subset of patients.

VERY BRIEF REVIEW: The article discusses the purpose of MTP in pediatric trauma patients, defines MTP, and discusses implications for standardizing MTP for pediatric trauma patients.

Background: Injury is the leading cause of death in children and adolescents with falls and motor vehicle accidents as the two leading mechanisms of injury. Bleeding from these mechanisms can be severe enough to warrant massive transfusion protocol (MTP) activations. Traumatic injury remains the main driver for activation of a pediatric MTP. This subset of trauma victims is generally older, more hypothermic, with a higher injury severity score when compared with other pediatric trauma patients who may have been transfused but did not meet the criteria for pediatric massive transfusion (MT). This review of massive transfusion protocols in pediatric patients consisted of a search of the PubMed and Google Scholar databases. We aim to not only summarize current evidence-based practices in pediatric massive transfusion but also to highlight future directions in this field and present ideas for future study to improve the care and outcomes of pediatric patients.

Methods: The article used databases to determine methods for evaluating effectiveness and outcomes for pediatric trauma patients requiring massive transfusion. Over the last several years, multiple pediatric studies have attempted to define MT in the pediatric population as the initial step towards developing prediction tools and refining protocols using retrospective data sets. This difficulty in a universal definition is apparent in the adult transfusion literature as well, with multiple competing definitions of MT, all seeking to adequately describe this patient population. This attempt to create a standardized definition as the foundation of further inquiry has been limited by the heterogeneity of patient populations studied and the difficulty in acquiring the granularity of detail required to adequately describe each MTP activation. From 2010 to 2012, 13,523 (4%) of the 356,583 pediatric patients in the National Trauma Data Bank required any amount of blood product transfusion within 24 h of injury. Of that group, 173 children (0.04%) required MT. While pediatric MTP activation is a fairly rare event, defining the population that will benefit is important to increase their survival.

Results: A majority of literature surrounding massive transfusion protocols in children and adults has focused on whole blood, packed red blood cells, FFP and platelet administration. While the importance of the balanced resuscitation concept has been repeatedly emphasized, more studies are needed. There is also a paucity of data to guide the use of adjuncts such as tranexamic acid and factor VII in children. Moving forward, the focus should broaden to include both a balanced transfusion strategy combined with adjuncts to combat the hyperfibrinolysis that accompanies the acute coagulopathy following massive hemorrhage.

Conclusion: Pediatric massive transfusion protocol activation is a fairly rare event and heralds a high probability of morbidity and mortality. The rarity poses a challenge in creating, implementing, standardizing and evaluating these pediatric massive transfusion protocols. However, the process of quality assurance (QA) requires accurate definition of terms. Pediatric massive transfusion protocol activation is a binary event, it is either activated or not.

PTS Summary: Although the use of the MTP in the pediatric population is infrequent, further studies are needed to improve patient outcomes

CME Opportunitues


There is a fee associated for non-members.
Damage control resuscitation: Explores the use of blood products and massive transfusion protocols with pediatric trauma patients.
Several studies supporting the use of damage control resuscitation measures exist with adult patients. The CME activity explores methods for damage control resuscitation with pediatric patients.


There is a fee associated for non-members
Blunt trauma is a leading cause of death for pediatric trauma patients. The activity reviews information about the move toward the use of massive transfusion protocols in pediatric trauma patients.

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