Tranexamic Acid Administration to Pediatric Trauma Patients in a Combat Setting: The Pediatric Trauma and Tranexamic Acid Atudy (PED-TRAX): Eckert MJ, Wertin TM, Tyner SD, et al. J Trauma Acute Care Surg 2014;77:852–8.

Abstract

Early administration of tranexamic acid (TXA) in adult trauma patients has been associated with decreased mortality and blood product administration. Limited data are available on the use of TXA in pediatric trauma. The goal of this study was to evaluate the use and efficacy of TXA in pediatric combat patients. The authors conducted a retrospective cohort study of all pediatric trauma admissions to the North Atlantic Treaty Organization Role 3 hospital, Camp Bastion, Afghanistan, from 2008 to 2012. All pediatric trauma patients < 18 years of age were included. The primary outcome for the study was mortality. Secondary outcomes included factors associated with TXA use and complications of TXA use. TXA administration was used at adult dosing, with a single fixed bolus dose of 1 g TXA administered within 3 h of injury. In total, 766 admitted pediatric trauma patients were included in the study, of which 10% received TXA. Overall injury severity score (ISS) for those treated with TXA was significantly higher than average (15 vs. 10, p < 0.05). Significant independent predictors of TXA administration were severe abdominal or extremity injury and severe metabolic acidosis, with base deficit > 5. However, the propensity analysis model showed significant unexplained variance in the decision to administer TXA with an R-squared value of .47. Unadjusted mortality was higher in patients who received TXA (15% vs. 9%), but this difference was not statistically significant (P = 0.06). After controlling for confounding factors including mechanism, injury severity, base deficit, hypotension, and Glasgow Coma Scale score, TXA administration was associated with reduced mortality (P = 0.03). There were nonstatistically significant trends toward improved survival in those patients receiving TXA in subpopulation analysis of those who received transfusions and those severely injured, with an ISS > 15. Analysis of additional outcomes besides mortality studied in propensity-matched groups of TXA vs. no TXA administration demonstrated advantage to the TXA group, with significantly improved neurologic status at the time of discharge or transfer, a higher likelihood of a near-normal GCS score, fewer patients with severe brain injury, and a lower likelihood of requiring mechanical ventilation at the time of discharge or transfer. There were no adverse outcomes associated with the administration of TXA. The authors concluded that the same favorable association of survival advantage and safety profile as seen in the adult trauma population held true in a pediatric trauma population, and furthermore, there may be added benefit of improved neurologic and pulmonary outcomes in patients treated with TXA. Limitations acknowledged by the authors included the retrospective nature of the study, and no information on blood loss or coagulation/thromboelastometry data, which limits the ability to directly measure the effects of TXA on blood loss or coagulation; and lack of data on timing of TXA administration of subsequent dosing. Another limitation noted was that the relatively small population might significantly limit safety conclusions.