Treshold for massive transfusion protocol in children

Infographic · Jan 2023 · 2 min read

In brief

This infographic presents research establishing >20 mL/kg of blood products within one hour as the optimal threshold for activating massive transfusion protocols in pediatric trauma patients. The study of 287 children found this threshold predicted mortality, need for urgent surgery, and recurrent bleeding with 70-77% sensitivity.

Activate massive transfusion protocol when pediatric trauma patients receive >20 mL/kg blood products within 1 hour.
Children meeting this 20 mL/kg threshold have 3.4× increased mortality odds and need urgent hemorrhage control.
Each additional unit of blood product transfused increases mortality risk by 10% in pediatric trauma patients.
Early recognition using this threshold enables timely hemostatic resuscitation in life-threatening pediatric hemorrhage.
The 20 mL/kg cutoff optimizes sensitivity (65-77%) and specificity (74-77%) for predicting adverse outcomes.

Written by the GCMD Library team from the infographic.

The infographic uses a red, white, and teal color scheme with three main sections. The left panel shows study parameters with icons for location, methodology, and timeline. The center panel illustrates the transfusion decision point with blood bag and drop icons. The right panel displays three outcome metrics with corresponding icons: a gravestone for mortality, an ambulance for urgent procedures, and a blood drop for bleeding episodes.

Infographic by Chilenian society of Pediaric Surgery

"Recognizing life-threatening bleeding in pediatric trauma: A standard for when to activate massive transfusion protocol"

Authors: Katrina M Morgan, Barbara A Gaines, Ward M Richardson, Stephen Strotmeyer, Christine M Leeper

Full article: https://pubmed.ncbi.nlm.nih.gov/36121215/

Abstract

Background: Traumatic hemorrhage is the most common cause of preventable death in civilian and military trauma. Early identification of pediatric life-threatening hemorrhage is challenging. There is no accepted clinical critical administration threshold (CAT) in children for activating massive transfusion protocols.

Methods: Children 0 to 17 years old who received any transfusion in the first 24 hours after injury between 2010 and 2019 were included. The type, volume, and time of administration for each product were recorded. The greatest volume of weight-adjusted products transfused within 1 hour was calculated. The cut point for the number of products that maximized sensitivity and specificity to predict in-hospital mortality, need for urgent surgery, and second life-threatening bleeding episode was determined using Youden's index. A binary variable (CAT+) was generated using this threshold for inclusion in a multivariable logistic regression model.

Results: In total, 287 patients were included. The median (interquartile range) age was 6 (2-14) years, 60% were males, 83% sustained blunt trauma, and the median (interquartile range) Injury Severity Score was 26 (17-35). The optimal cutoff to define CAT+ was >20 mL/kg of product; this optimized test characteristics for mortality (sensitivity, 70%; specificity, 77%), need for urgent hemorrhage control procedure (sensitivity, 65%; specificity, 74%). and second bleeding episode (sensitivity, 77%; specificity, 74%). There were 93 children (32%) who were CAT+. On multivariate regression, being CAT+ was associated with 3.4 increased odds of mortality (95% confidence interval, 1.67-6.89; p = 0.001) after controlling for age, hypotension, Injury Severity Score, and Glasgow Coma Scale. For every unit of product administered, there was a 10% increased risk of mortality (odds ratio, 1.1; p < 0.001).

Conclusion: Transfusion of more than 20 mL/kg of any blood product within an hour should be used as a threshold for activating massive transfusion protocols in children. Children who meet this CAT are at high risk of mortality and need for interventions; this population may benefit from targeted, timely, and aggressive hemostatic resuscitation.

Level of evidence: Therapeutic/Care Management; Level III.

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