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 (MTP).
Methods: Children 0-17 years old who received any transfusion in the first 24-hours after injury between 2010-2019 were included. The type, volume, and time of administration for each product was recorded. The greatest volume of weight-adjusted products transfused within one 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(IQR) age was 6(2-14) years, 60% were males, 83% sustained blunt trauma, and median(IQR) Injury Severity Score (ISS) 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(32%) children who were CAT+. On multivariate regression, being CAT+ was associated with 3.4 increased odds of mortality (95% CI = 1.67-6.89, p = 0.001) after controlling for age, hypotension, ISS, and Glasgow Coma Scale. For every unit of product administered, there was a 10% increased risk of mortality (OR = 1.1, p < 0.001).
Conclusions: 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 critical administration threshold are at high risk of mortality and need for interventions; this population may benefit from targeted, timely, and aggressive hemostatic resuscitation.
DOI: 10.1097/TA.0000000000003784
