Abstract
Haemorrhage is a leading cause of death in paediatric trauma patients. Predefined massive transfusion protocols (MTP) have the potential to significantly reduce mortality by treating haemorrhagic shock and coagulopathy, in adhering to the principles of haemostatic resuscitation with rapid administration of balanced ratios of packed red blood cells (RBC), fresh frozen plasma (FFP) and platelets (PLT).Because of their substantial physiological reserve, initial vital signs may not be good predictors of early haemorrhage in paediatric patients. Determining the triggers for MTP activation in paediatric trauma patients is challenging, and the optimal blood product ratio that will increase survival in massively bleeding paediatric trauma patients has yet to be determined. To date, only a few small descriptive studies and case reports have investigated the use of predefined MTP in paediatric trauma patients.MTP with increased FFP or PLT to RBC ratios combined with viscoelastic haemostatic assay (VHA) guided haemostatic resuscitation have not yet been tested in paediatric populations but based on results from adult trauma patients, this therapeutic approach seems promising.Considering the high prevalence of early coagulopathy in paediatric trauma patients, immediate identification and implementation of VHA-directed treatment of traumatic coagulopathy could ensure faster haemostasis and thereby, potentially, reduce bleeding as well as the total transfusion requirements and further improve outcome in paediatric trauma patients. Prospective randomized trials investigating this therapeutic approach in paediatric trauma patients are highly warranted.
Highlights
Injuries account for an estimated 950,000 deaths annually in children less than 18 years of age and in highincome countries, injuries cause nearly 40% of all child deaths [1]
The purpose of this review is to summarise the current evidence regarding transfusion therapy in massively bleeding paediatric trauma patients
Both adult and paediatric patients with uncontrolled bleeding are treated with predefined transfusion packages, based on haemostatic resuscitation (HR) principles involving early administration of fresh frozen plasma (FFP) and PLT [80]
Summary
Injuries account for an estimated 950,000 deaths annually in children less than 18 years of age and in highincome countries, injuries cause nearly 40% of all child deaths [1]. The use of VHA to assess coagulopathy and to guide blood transfusion therapy has been recommended in the recent European guidelines regarding management of massively bleeding trauma patients [68] At our institution, both adult and paediatric patients with uncontrolled bleeding are treated with predefined transfusion packages, based on HR principles involving early administration of FFP (pre-thawed plasma is always available for immediate delivery) and PLT (whole blood derived platelet concentrate) [80]. Based on the results of real-time TEG® analyses, goal-directed treatment with specific blood products and pro-coagulant adjuvants (tranexamic acid, cryoprecipitate, fibrinogen) are administered according to protocol and expert opinion, basing interventions primarily on the clinical presentation of the patient together with the real time TEG® results The implementation of this MTP has led to increased survival of massively bleeding adult patients at our institution [15,80], but results from paediatric data are still pending. Like that observed for RBC, plasma transfusions have been found to be independently associated with an increased occurrence of new or progressive MOF, Ongoing bleeding
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