Skip to main content
SpringerLink
Log in

Massive Transfusion Protocols in the Pediatric Trauma Patient: An Update

  • Pediatric Trauma Surgery (A. Fischer, Section Editor)
  • Published:
Current Surgery Reports Aims and scope Submit manuscript

Abstract

There has been significant research dedicated to damage control resuscitation in adult trauma patients with hemorrhagic shock. Balanced blood product resuscitation with restriction of crystalloid has demonstrated improved outcomes in such patients. But to date, there has been insufficient evidence to determine the best resuscitation strategy for severely injured children suffering from exsanguination. Nonetheless, massive transfusion protocols developed for the adult population have been modified and widely implemented for children. Despite the experiences gained during the recent military conflicts overseas and at civilian trauma centers, there continues to be a lack of evidence regarding optimal resuscitation strategies for children in hemorrhagic shock.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Borgman MA, et al. Pediatric trauma BIG score: predicting mortality in children after military and civilian trauma. Pediatrics. 2011;127(4):e892–7.

    Article  PubMed  Google Scholar 

  2. •• Nosanov L, et al. The impact of blood product ratios in massively transfused pediatric trauma patients. Am J Surg. 2013;206(5):655–60. This is a retrospective analysis evaluating the effects of blood product ratios on massively transfused pediatric trauma patients. They found higher ratios of FFP and platelets to pRBCs did not have a mortality benefit. Ultimately, they showed early and aggressive transfusion may not be optimal in this population and needs further prospective study.

  3. Hamilton BE, et al. Annual summary of vital statistics: 2010–2011. Pediatrics. 2013;131(3):548–58.

    Article  PubMed  Google Scholar 

  4. Centers for Disease Control and Prevention (CDC). Vital signs: unintentional injury deaths among persons aged 0–19 years—United States, 2000–2009. Morb Mortal Wkly Rep. 2012;61:270–6.

    Google Scholar 

  5. Burd RS, Jang TS, Nair SS. Evaluation of the relationship between mechanism of injury and outcome in pediatric trauma. J Trauma. 2007;62(4):1004–14.

    Article  PubMed  Google Scholar 

  6. Borgman MA, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007;63(4):805–13.

    Article  PubMed  Google Scholar 

  7. •• Holcomb JB, et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013;148(2):127–36. Given most literature concerning resuscitation strategies is retrospective, this group performed a large prospective study to determine the effects of early and balanced component transfusion. They found higher plasma and platelet ratios transfused early were associated with a 24-hour mortality benefit.

  8. Holcomb JB, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg. 2008;248(3):447–58.

    PubMed  Google Scholar 

  9. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006;60(6 Suppl):S3–11.

    Article  PubMed  Google Scholar 

  10. Choi PM, Vogel AM. Acute coagulopathy in pediatric trauma. Curr Opin Pediatr. 2014;26(3):343–9.

    Article  CAS  PubMed  Google Scholar 

  11. Greene N, Bhananker S, Ramaiah R. Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma. Int J Crit Illn Inj Sci. 2012;2(3):135–42.

    Article  PubMed Central  PubMed  Google Scholar 

  12. McFadyen JG, Ramaiah R, Bhananker SM. Initial assessment and management of pediatric trauma patients. Int J Crit Illn Inj Sci. 2012;2(3):121–7.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Joint Theater Trauma System Clinical Practice Guideline. Damage control resuscitation at level IIb/III treatment facilities. In: J.T.T.S.C.P. Guideline, editor. Joint Trauma System; 2013. http://www.usaisr.amedd.army.mil/cpgs/Damage%20Control%20Resuscitation%20-%201%20Feb%202013.pdf. Accessed 01 Jan 2015.

  14. Peterson SR, Weinbery JA. Transfusion, autotransfusion, and blood substitutes. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. Chicago: McGraw Hill; 2008. p. 235–43.

    Google Scholar 

  15. Brohi K, et al. Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg. 2007;245(5):812–8.

    Article  PubMed Central  PubMed  Google Scholar 

  16. Brohi K, et al. Acute traumatic coagulopathy. J Trauma. 2003;54(6):1127–30.

    Article  PubMed  Google Scholar 

  17. • Hendrickson JE, et al. Coagulopathy is prevalent and associated with adverse outcomes in transfused pediatric trauma patients. J Pediatr. 2012;160(2):204–9;e3. Pediatric trauma patients were both retrospectively and prospectively studied to investigate the effects of coagulopathy on this population. They found abnormal coagulation studies in a majority of the patients that were associated with an increase in mortality.

  18. MacLeod JB, et al. Early coagulopathy predicts mortality in trauma. J Trauma. 2003;55(1):39–44.

    Article  PubMed  Google Scholar 

  19. Frith D, Brohi K. The acute coagulopathy of trauma shock: clinical relevance. Surgeon. 2010;8(3):159–63.

    Article  PubMed  Google Scholar 

  20. Hiippala ST, Myllyla GJ, Vahtera EM. Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates. Anesth Analg. 1995;81(2):360–5.

    CAS  PubMed  Google Scholar 

  21. Haas T, et al. Perioperative course of FXIII in children undergoing major surgery. Paediatr Anaesth. 2012;22(7):641–6.

    Article  PubMed  Google Scholar 

  22. Hewson JR, et al. Coagulopathy related to dilution and hypotension during massive transfusion. Crit Care Med. 1985;13(5):387–91.

    Article  CAS  PubMed  Google Scholar 

  23. Phillips CR, et al. Resuscitation of haemorrhagic shock with normal saline vs. lactated Ringer’s: effects on oxygenation, extravascular lung water and haemodynamics. Crit Care. 2009;13(2):R30.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Bolliger D, et al. Haemodilution-induced profibrinolytic state is mitigated by fresh-frozen plasma: implications for early haemostatic intervention in massive haemorrhage. Br J Anaesth. 2010;104(3):318–25.

    Article  CAS  PubMed  Google Scholar 

  25. • Diab YA, Wong EC, Luban NL. Massive transfusion in children and neonates. Br J Haematol. 2013;161(1):15–26. This is a comprehensive review of massive transfusions in children and neonates. It offers an in depth review of coagulopathy in pediatrics along with the complications associated with transfusions. In addition, they offer an example of their MTP along with information regarding ECMO in children.

  26. Brohi K, et al. Acute coagulopathy of trauma: hypoperfusion induces systemic anticoagulation and hyperfibrinolysis. J Trauma. 2008;64(5):1211–7; discussion 1217.

    Article  PubMed  Google Scholar 

  27. Kuhle S, Male C, Mitchell L. Developmental hemostasis: pro- and anticoagulant systems during childhood. Semin Thromb Hemost. 2003;29(4):329–38.

    Article  CAS  PubMed  Google Scholar 

  28. Lustenberger T, et al. Early coagulopathy after isolated severe traumatic brain injury: relationship with hypoperfusion challenged. J Trauma. 2010;69(6):1410–4.

    Article  PubMed  Google Scholar 

  29. Talving P, et al. Coagulopathy after isolated severe traumatic brain injury in children. J Trauma. 2011;71(5):1205–10.

    Article  PubMed  Google Scholar 

  30. Davenport R, et al. Functional definition and characterization of acute traumatic coagulopathy. Crit Care Med. 2011;39(12):2652–8.

    PubMed Central  PubMed  Google Scholar 

  31. Vogel AM, et al. Admission rapid thrombelastography delivers real-time “actionable” data in pediatric trauma. J Pediatr Surg. 2013;48(6):1371–6.

    Article  PubMed  Google Scholar 

  32. Nylund CM, et al. Thromboelastography to direct the administration of recombinant activated factor VII in a child with traumatic injury requiring massive transfusion. Pediatr Crit Care Med. 2009;10(2):e22–6.

    Article  PubMed  Google Scholar 

  33. Malone DL, Hess JR, Fingerhut A. Massive transfusion practices around the globe and a suggestion for a common massive transfusion protocol. J Trauma. 2006;60(6 Suppl):S91–6.

    Article  PubMed  Google Scholar 

  34. Shaz BH, et al. Transfusion management of trauma patients. Anesth Analg. 2009;108(6):1760–8.

    Article  PubMed Central  PubMed  Google Scholar 

  35. Cap AP, et al. Timing and location of blood product transfusion and outcomes in massively transfused combat casualties. J Trauma Acute Care Surg. 2012;73(2 Suppl 1):S89–94.

    Article  PubMed  Google Scholar 

  36. Kashuk JL, et al. Postinjury life threatening coagulopathy: is 1:1 fresh frozen plasma:packed red blood cells the answer? J Trauma. 2008;65(2):261–70; discussion 270–1.

    Article  PubMed  Google Scholar 

  37. Mitra B, et al. Fresh frozen plasma (FFP) use during massive blood transfusion in trauma resuscitation. Injury. 2010;41(1):35–9.

    Article  PubMed  Google Scholar 

  38. Pidcoke HF, et al. Ten-year analysis of transfusion in operation iraqi freedom and operation enduring freedom: increased plasma and platelet use correlates with improved survival. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S445–52.

    Article  PubMed  Google Scholar 

  39. Rahbar E, et al. Early resuscitation intensity as a surrogate for bleeding severity and early mortality in the PROMMTT study. J Trauma Acute Care Surg. 2013;75(1 Suppl 1):S16–23.

    Article  PubMed Central  PubMed  Google Scholar 

  40. Riskin DJ, et al. Massive transfusion protocols: the role of aggressive resuscitation versus product ratio in mortality reduction. J Am Coll Surg. 2009;209(2):198–205.

    Article  PubMed  Google Scholar 

  41. Scalea TM, et al. Early aggressive use of fresh frozen plasma does not improve outcome in critically injured trauma patients. Ann Surg. 2008;248(4):578–84.

    PubMed  Google Scholar 

  42. •• Neff LP, et al. Clearly defining pediatric massive transfusion: cutting through the fog and friction with combat data. J Trauma Acute Care Surg. 2015;78(1):22–9. As most definitions of MTs in pediatric patients are not well validated, this group set out to determine a definition based on a large retrospective analysis of patients injured in a combat setting. Their goal was to develop a MT definition to capture patients at risk for shock and to aid in the development of transfusion guidelines. They found 40 mL/kg of any blood product was predictive of mortality and thought this was a reasonable definition of a MT in the pediatric trauma patient.

  43. Duchesne JC, et al. Review of current blood transfusions strategies in a mature level I trauma center: were we wrong for the last 60 years? J Trauma. 2008;65(2):272–6; discussion 276–8.

    Article  PubMed  Google Scholar 

  44. Gunter OL Jr, et al. Optimizing outcomes in damage control resuscitation: identifying blood product ratios associated with improved survival. J Trauma. 2008;65(3):527–34.

    Article  PubMed  Google Scholar 

  45. Maegele M, et al. Red-blood-cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiple injury: a retrospective analysis from the Trauma Registry of the Deutsche Gesellschaft fur Unfallchirurgie. Vox Sang. 2008;95(2):112–9.

    Article  CAS  PubMed  Google Scholar 

  46. Teixeira PG, et al. Impact of plasma transfusion in massively transfused trauma patients. J Trauma. 2009;66(3):693–7.

    Article  PubMed  Google Scholar 

  47. Zink KA, et al. A high ratio of plasma and platelets to packed red blood cells in the first 6 hours of massive transfusion improves outcomes in a large multicenter study. Am J Surg. 2009;197(5):565–70; discussion 570.

    Article  PubMed  Google Scholar 

  48. Sperry JL, et al. An FFP:PRBC transfusion ratio ≥ 1:1.5 is associated with a lower risk of mortality after massive transfusion. J Trauma. 2008;65(5):986–93.

    Article  PubMed  Google Scholar 

  49. del Junco DJ, et al. Resuscitate early with plasma and platelets or balance blood products gradually: findings from the PROMMTT study. J Trauma Acute Care Surg. 2013;75(1 Suppl 1):S24–30.

    Article  PubMed Central  PubMed  Google Scholar 

  50. •• Edwards MJ, Lustik MB, Clark ME, Creamer KM, Tuggle D. The effect of balanced the effects of balanced blood component resuscitation and crystalloid administration in pediatric trauma patients requiring transfusion in Afghanistan and Iraq 2002 to 2012. J Trauma Acute Care Surg. 2015;78(2):330–5. In order to address the effects of balanced component resuscitation and the infusion of crystalloid on pediatric trauma patients, this group evaluated children injured in OEF/OIF. They found no survival benefit in patients receiving early and higher ratios of blood components. Also, patients receiving more than 150 mL/kg of crystalloid had worse outcomes.

  51. Kleinman ME, et al. Part 14: pediatric advanced life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S876–908.

    Article  PubMed  Google Scholar 

  52. Allen CJ, et al. Initial hematocrit predicts the use of blood transfusion in the pediatric trauma patient. J Pediatr Surg. 2014;49(11):1678–82.

    Article  PubMed  Google Scholar 

  53. Cotton BA, et al. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J Trauma. 2009;66(1):41–8; discussion 48–9.

    Article  PubMed  Google Scholar 

  54. McLaughlin DF, et al. A predictive model for massive transfusion in combat casualty patients. J Trauma. 2008;64(2 Suppl):S57–63; discussion S63.

    Article  PubMed  Google Scholar 

  55. Nunez TC, et al. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma. 2009;66(2):346–52.

    Article  PubMed  Google Scholar 

  56. Cotton BA, et al. Multicenter validation of a simplified score to predict massive transfusion in trauma. J Trauma. 2010;69(Suppl 1):S33–9.

    Article  PubMed  Google Scholar 

  57. Yucel N, et al. Trauma associated severe hemorrhage (TASH)-score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma. J Trauma. 2006;60(6):1228–36.

    Article  PubMed  Google Scholar 

  58. Borgman MA, et al. The effect of FFP:RBC ratio on morbidity and mortality in trauma patients based on transfusion prediction score. Vox Sang. 2011;101(1):44–54.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  59. • Callcut RA, et al. Defining when to initiate massive transfusion: a validation study of individual massive transfusion triggers in PROMMTT patients. J Trauma Acute Care Surg. 2013;74(1):59–65, 67–8; discussion 66–7. In a subset analysis of the PROMMTT database, this group evaluated clinical triggers and their ability to predict the need for a MT. They found certain triggers were able to accurately predict need for a large amount of blood products. While this is evaluating adult patients, it provides potential triggers in the pediatric population in order to allow prompt initiation of transfusion.

  60. Callcut RA, et al. All massive transfusion criteria are not created equal: defining the predictive value of individual transfusion triggers to better determine who benefits from blood. J Trauma. 2011;70(4):794–801.

    Article  PubMed  Google Scholar 

  61. Dehmer JJ, Adamson WT. Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg. 2010;19(4):286–91.

    Article  PubMed  Google Scholar 

  62. Lee AC, et al. Transfusion-associated hyperkalemic cardiac arrest in pediatric patients receiving massive transfusion. Transfusion. 2014;54(1):244–54.

    Article  PubMed  Google Scholar 

  63. Maitland K, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364(26):2483–95.

    Article  CAS  PubMed  Google Scholar 

  64. Acker SN, et al. Blood component transfusion increases the risk of death in children with traumatic brain injury. J Trauma Acute Care Surg. 2014;76(4):1082–7; discussion 1087–8.

    Article  PubMed  Google Scholar 

  65. Pieracci FM, et al. Early death and late morbidity after blood transfusion of injured children: a pilot study. J Pediatr Surg. 2012;47(8):1587–91.

    Article  PubMed  Google Scholar 

  66. •• Hendrickson JE, et al. Implementation of a pediatric trauma massive transfusion protocol: one institution’s experience. Transfusion. 2012;52(6):1228–36. In this single center study, the clinical outcomes in pediatric trauma patients were assessed pre and post MTP implementation. While they showed employment of MTP is feasible, no improvement in clinical outcomes or mortality was seen after MTP initiation.

  67. •• Chidester SJ, et al. A pediatric massive transfusion protocol. J Trauma Acute Care Surg. 2012;73(5):1273–7. This is a prospective study evaluating outcomes in pediatric trauma patients assigned to 2 cohorts: one transfused per MTP and another per physician preference. They found no difference in mortality between the two groups; however, did find increased thromboembolic events in the non-MTP group.

  68. Dressler AM, et al. Use of a massive transfusion protocol with hemostatic resuscitation for severe intraoperative bleeding in a child. J Pediatr Surg. 2010;45(7):1530–3.

    Article  PubMed  Google Scholar 

  69. Paterson NA. Validation of a theoretically derived model for the management of massive blood loss in pediatric patients - a case report. Paediatr Anaesth. 2009;19(5):535–40.

    Article  PubMed  Google Scholar 

  70. Pickett PM, Tripi PA. Massive transfusion protocol in pediatric trauma. Int Anesthesiol Clin. 2011;49(2):62–7.

    Article  PubMed  Google Scholar 

  71. Ranucci M, et al. Duration of red blood cell storage and outcomes in pediatric cardiac surgery: an association found for pump prime blood. Crit Care. 2009;13(6):R207.

    Article  PubMed Central  PubMed  Google Scholar 

  72. Manlhiot C, et al. Longer blood storage is associated with suboptimal outcomes in high-risk pediatric cardiac surgery. Ann Thorac Surg. 2012;93(5):1563–9.

    Article  PubMed  Google Scholar 

  73. Morrison JJ, et al. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study. Arch Surg. 2012;147(2):113–9.

    Article  CAS  PubMed  Google Scholar 

  74. Morrison JJ, et al. Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury: findings from the MATTERs II Study. JAMA Surg. 2013;148(3):218–25.

    Article  CAS  PubMed  Google Scholar 

  75. Roberts I, et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013;17(10):1–79.

    Article  CAS  Google Scholar 

  76. Pasquali SK, et al. Comparative analysis of antifibrinolytic medications in pediatric heart surgery. J Thorac Cardiovasc Surg. 2012;143(3):550–7.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  77. Sethna NF, et al. Tranexamic acid reduces intraoperative blood loss in pediatric patients undergoing scoliosis surgery. Anesthesiology. 2005;102(4):727–32.

    Article  CAS  PubMed  Google Scholar 

  78. Song G, et al. Tranexamic Acid reducing blood transfusion in children undergoing craniosynostosis surgery. J Craniofac Surg. 2013;24(1):299–303.

    Article  PubMed  Google Scholar 

  79. Eckert MJ, et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 2014;77(6):852–8.

    Article  CAS  PubMed  Google Scholar 

  80. Barcelona SL, Thompson AA, Cote CJ. Intraoperative pediatric blood transfusion therapy: a review of common issues. Part II: transfusion therapy, special considerations, and reduction of allogenic blood transfusions. Paediatr Anaesth. 2005;15(10):814–30.

    Article  PubMed  Google Scholar 

  81. Parker RI. Transfusion in critically ill children: indications, risks, and challenges. Crit Care Med. 2014;42(3):675–90.

    Article  PubMed  Google Scholar 

  82. Levi M, et al. Safety of recombinant activated factor VII in randomized clinical trials. N Engl J Med. 2010;363(19):1791–800.

    Article  CAS  PubMed  Google Scholar 

  83. Simpson E, et al. Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. Cochrane Database Syst Rev. 2012;3:Cd005011.

    PubMed  Google Scholar 

  84. Hauser CJ, et al. Results of the CONTROL trial: efficacy and safety of recombinant activated Factor VII in the management of refractory traumatic hemorrhage. J Trauma. 2010;69(3):489–500.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA

    Michelle Buehner & Mary J. Edwards

Authors
  1. Michelle Buehner
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mary J. Edwards
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michelle Buehner.

Additional information

This article is part of the Topical Collection on Pediatric Trauma Surgery.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Buehner, M., Edwards, M.J. Massive Transfusion Protocols in the Pediatric Trauma Patient: An Update. Curr Surg Rep 3, 15 (2015). https://doi.org/10.1007/s40137-015-0092-3

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s40137-015-0092-3

Keywords

Search

Navigation