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Canadian tertiary care pediatric massive hemorrhage protocols: a survey and comprehensive national review

Protocoles canadiens de soins tertiaires pour les hémorragies massives en pédiatrie : un sondage et un examen national exhaustif

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Abstract

Purpose

Hemorrhage is the leading cause of pediatric death in trauma and cardiac arrest during surgery. Adult studies report improved patient outcomes using massive hemorrhage protocols (MHPs). Little is known about pediatric MHP adoption in Canada.

Methods

After waived research ethics approval, we conducted a survey of Canadian pediatric tertiary care hospitals to study MHP activations. Transfusion medicine directors provided hospital/patient demographic and MHP activation data. The authors extracted pediatric-specific MHP data from requested policy/procedure documents according to seven predefined MHP domains based on the literature. We also surveyed educational and audit tools. The analysis only included MHPs with pediatric-specific content.

Results

The survey included 18 sites (100% response rate). Only 13/18 hospitals had pediatric-specific MHP content: eight were dedicated pediatric hospitals, two were combined pediatric/obstetrical hospitals, and three were combined pediatric/adult hospitals. Trauma was the most common indication for MHP activation (54%), typically based on a specific blood volume anticipated/transfused over time (10/13 sites). Transport container content was variable. Plasma and platelets were usually not in the first container. There was little emphasis on balanced plasma/platelet to red-blood-cell ratios, and most sites (12/13) rapidly incorporated laboratory-guided goal-directed transfusion. Transfusion thresholds were consistent with recent guidelines. All protocols used tranexamic acid and eight sites used an audit tool.

Discussion/Conclusion

Pediatric MHP content was highly variable. Activation demographics suggest underuse in nontrauma settings. Our findings highlight the need for a consensus definition for pediatric massive hemorrhage, a validated pediatric MHP activation tool, and prospective assessment of blood component ratios. A national pediatric MHP activation repository would allow for quality improvement metrics.

Résumé

Objectif

L’hémorragie est la principale cause de décès pédiatrique dans les cas de traumatismes et les arrêts cardiaques pendant la chirurgie. Les études menées chez l’adulte font état d’une amélioration des devenirs pour les patient·es lors de l’utilisation de protocoles d’hémorragie massive (PHM). On ne connait que peu de choses quant à l’adoption des PHM pédiatriques au Canada.

Méthode

Après avoir été dispensés de l’approbation du comité d’éthique de la recherche, nous avons mené un sondage auprès des hôpitaux de soins tertiaires pédiatriques canadiens pour étudier les activations des PHM. Les directions responsables de la médecine transfusionnelle ont fourni des données démographiques sur les hôpitaux et la patientèle et sur l’activation des PHM. Nous avons extrait les données sur les PHM spécialement conçus pour les enfants à partir des documents de politiques et de procédures demandés selon sept domaines de PHM prédéfinis en nous fondant sur la littérature. Nous avons également examiné les outils éducatifs et de vérification. L’analyse n’a inclus que les PHM disposant d’un contenu spécifique à la pédiatrie.

Résultats

L’enquête comprenait 18 sites (taux de réponse de 100 %). Seuls 13/18 hôpitaux disposaient de contenu spécifique à la pédiatrie dans leurs PHM : huit étaient des hôpitaux pédiatriques dédiés, deux des hôpitaux pédiatriques/obstétricaux combinés, et trois des hôpitaux pédiatriques/adultes combinés. Le traumatisme était l’indication la plus fréquente d’activation d’un PHM (54 %), généralement fondé sur un volume sanguin spécifique anticipé/transfusé au fil du temps (10/13 sites). Le contenu du conteneur de transport était variable. Le plasma et les plaquettes n’étaient généralement inclus pas dans le premier récipient. Il n’y avait que peu d’emphase sur les ratios plasma/plaquettes et globules rouges équilibrés, et la plupart des sites (12/13) ont rapidement incorporé les protocoles de transfusion ciblée guidés par les tests sanguins de laboratoire. Les seuils de transfusion étaient conformes aux lignes directrices récentes. Tous les protocoles utilisaient de l’acide tranexamique et huit sites utilisaient un outil de vérification.

Discussion/Conclusion

Le contenu des PHM pédiatriques était très variable. Les données démographiques sur l’activation suggèrent une sous-utilisation dans les contextes non traumatiques. Nos résultats soulignent la nécessité d’une définition consensuelle de l’hémorragie massive pédiatrique, d’un outil d’activation pédiatrique validé du PHM et d’une évaluation prospective des ratios des composants sanguins. Un recueil national d’activation des PHM pédiatriques permettrait d’obtenir des mesures d’amélioration de la qualité.

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Author contributions

Valérie Arsenault and Lani Lieberman contributed to all aspects of this manuscript, including study conception and design; acquisition, analysis, and interpretation of data; and reviewing/editing the article. Pegah Akbari contributed to the design and deployment of the survey and building the RedCap© database, analysis, and interpretation of data and reviewing/editing the article. Kimmo Murto contributed to most aspects of this manuscript, including study conception and design; analysis, and interpretation of data; and drafting the article.

Acknowledgement

Thank you to Johanna Spaans for reviewing and editing the manuscript.

Disclosures

Drs Lani Lieberman and Kimmo Murto have an ongoing noncommercial and unfunded relationship with the Ontario Regional Blood Coordinating Network (ORBCoN), an Ontario Ministry of Health funded organization, in the design, development, deployment and monitoring of a province-wide standardized massive hemorrhage protocol for children. Dr Valerie Arsenault and Pegah Akbari have no conflicts of interest.

Funding statement

There was no funding source.

Prior conference presentations

Preliminary study dated was presented by Valérie Arsenault at the virtual 2021 Canadian Society for Transfusion Medicine Annual Conference (13–15 May, Moncton, NB, Canada).

Editorial responsibility

This submission was handled by Dr. Vishal Uppal, Associate Editor, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.

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Author notes

  1. Lani Lieberman and Kimmo Murto have contributed equally to this work and share senior authorship.

Authors and Affiliations

  1. Division of Transfusion Medicine, Department of Laboratory Medicine, University of Montreal, Montreal, QC, Canada

    Valérie Arsenault MD, MEd, FRCPC

  2. Centre Hospitalier Universitaire (CHU) Sainte-Justine, Mother and Child Hospital of Montreal, Montreal, QC, Canada

    Valérie Arsenault MD, MEd, FRCPC

  3. Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, ON, Canada

    Lani Lieberman MD, FRCPC

  4. University Health Network, Toronto General Hospital, Toronto, ON, Canada

    Lani Lieberman MD, FRCPC

  5. Department of Physical Therapy, University of Toronto, Toronto, ON, Canada

    Pegah Akbari MSc, MScPT

  6. Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada

    Kimmo Murto MD, FRCPC

  7. Children’s Hospital of Eastern Ontario Research Institute, 401 Smyth Rd., Ottawa, ON, K1H 8L1, Canada

    Kimmo Murto MD, FRCPC

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the Canadian Obstetrical Pediatric Transfusion Network

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Correspondence to Kimmo Murto MD, FRCPC.

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Arsenault, V., Lieberman, L., Akbari, P. et al. Canadian tertiary care pediatric massive hemorrhage protocols: a survey and comprehensive national review. Can J Anesth/J Can Anesth 71, 453–464 (2024). https://doi.org/10.1007/s12630-023-02641-w

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