Blood Product Ratios Research Articles

Management of massive haemorrhage in transfusion medicine services in the Middle East and North Africa.

Massive transfusion protocols (MTPs) are critical in managing haemorrhage, yet their utilization varies. There is lack of data on the utilization of MTPs in the Middle East and North Africa (MENA) region. This study aims to assess the degree of utilization of MTPs in the region. We conducted a survey to collect data on MTP use, inviting medical directors of transfusion services from various hospitals. Data were analysed to determine the prevalence of MTP utilization, their compositions, challenges in application and areas of future need. Eighteen respondents participated, representing 11 countries in the region. Thirteen hospitals implemented MTP, and eight included paediatrics. Eleven institutions used more than one definition of massive haemorrhage, with the most common being ≥10 red blood cell (RBC) units transfused for adults and replacement of >50% total blood volume in paediatrics. The majority of sites with MTPs utilized 1:1:1 RBCs:platelets:plasma ratio (70%). Variations were observed in the types and blood groups of components used. Two sites utilized whole blood, while six are considering it for future use. Utilization of adjunctive agents and frequency of laboratory testing varied among the sites. Challenges included the lack of medical expertise in protocol development, adherence and paediatric application. The need assessment emphasized the need for developing regional guidelines, standardized protocols and training initiatives. Although several hospitals have adopted MTPs, variations exist in activation criteria, blood product ratios and monitoring. Challenges include the lack of medical expertise, protocol adherence and addressing paediatric needs. Standardizing protocols, enhancing training and paediatric application are crucial for improving massive transfusion management in the region.

High Fresh Frozen Plasma to Red Blood Cell Ratio and Survival Outcomes in Blunt Trauma

Current trauma-care protocols advocate early administration of fresh frozen plasma (FFP) in a ratio close to 1:1 with red blood cells (RBCs) to manage trauma-induced coagulopathy in patients with severe blunt trauma. However, the benefits of a higher FFP to RBC ratio have not yet been established. To investigate the effectiveness of a high FFP to RBC transfusion ratio in the treatment of severe blunt trauma and explore the nonlinear relationship between the ratio of blood products used and patient outcomes. This was a multicenter cohort study retrospectively analyzing data from the Japan Trauma Data Bank, including adult patients with severe blunt trauma without severe head injury (Injury Severity Score ≥16 and head Abbreviated Injury Scale <3) between 2019 and 2022. Patients were categorized into 2 groups based on the ratio of FFP to RBC: the high-FFP group (ratio >1) and the low-FFP group (ratio ≤1). All-cause in-hospital mortality was the primary outcome. Additionally, the occurrence of transfusion-related adverse events was evaluated. Among the 1954 patients (median [IQR] age, 61 [41-77] years; 1243 male [63.6%]) analyzed, 976 (49.9%) had a high FFP to RBC ratio. Results from logistic regression, weighted by inverse probability treatment weighting, demonstrated an association between the group with a high-FFP ratio and lower in-hospital mortality (odds ratio, 0.73; 95% CI, 0.56-0.93) compared with a low-FFP ratio. Nonlinear trends were noted, suggesting a potential ceiling effect on transfusion benefits. In this cohort study, a high FFP to RBC ratio was associated with favorable survival in patients with severe blunt trauma. These outcomes highlight the importance of revising the current transfusion protocols to incorporate a high FFP to RBC ratio, warranting further research on optimal patient treatment.

Real-time performance improvement optimizes damage control resuscitation best practice adherence: Results of a pilot prospective observational study.

Maintaining balanced blood product ratios during damage control resuscitation (DCR) is independently associated with improved survival. We hypothesized that real-time performance improvement (RT-PI) would increase adherence to DCR best practice. From December 2020-August 2021, we prospectively used a bedside RT-PI tool to guide DCR in severely injured patients surviving at least 30 min. RT-PI study patients were compared to contemporary control patients at our institution and historic PROMMTT study patients. A subset of patients transfused ≥6 U red blood cells (RBC) in 6 h (MT+) was also identified. The primary endpoint was percentage time in a high ratio range (≥3:4) of plasma (PLAS):RBC and platelet (PLT):RBC over 6 h. Secondary endpoints included time to massive transfusion protocol activation, time to calcium and tranexamic acid (TXA) dosing, and cumulative 6-h ratios. Included patients (n = 772) were 35 (24-51) years old with an Injury Severity Score of 27 (17-38) and 42% had penetrating injuries. RT-PI (n = 10) patients spent 96% of the 6-h resuscitation in a high PLAS:RBC range, no different versus CONTROL (n = 87) (96%) but more than PROMMTT (n = 675) (25%, p < .001). In the MT+ subgroup, optimal PLAS:RBC and PLT:RBC were maintained for the entire 6 h in RT-PI (n = 4) versus PROMMTT (n = 391) patients for both PLAS (p < .001) and PLT ratios (p < .001). Time to TXA also improved significantly in RT-PI versus CONTROL patients (27 min [22-31] vs. 51 min [29-98], p = .035). In this prospective study, RT-PI was associated with optimized DCR. Multicenter validation of this novel approach to optimizing DCR implementation is warranted.

Predictors of Clinical Outcomes and the Need for Massive Transfusion Protocols in Geriatric Trauma Patients With Hemorrhagic Shock: A Systematic Review.

The current literature lacks a clear consensus on the predictors of mortality and outcomes of geriatric trauma patients in hemorrhagic shock. This systematic review aims to investigate predictors of clinical outcomes and the need for massive transfusion protocol in the geriatric trauma population with hemorrhagic shock. PubMed, EMBASE, Cochrane, ProQuest, and Google Scholar were searched for studies evaluating geriatric trauma patients in hemorrhagic shock or receiving MTP. Outcomes of interest included the effect of advanced age on clinical outcomes, the accuracy of SI and other variables in predicting mortality and need for MTP, and associations between blood product ratio and clinical outcomes. Fifteen studies were included in this systematic review. In most studies, advanced age was an accurate predictor of mortality and complication rates in geriatric patients undergoing management of shock with MTP. SI along with other variables such as systolic blood pressure (SBP) were sensitive predictors of mortality and the need for MTP. Studies evaluating blood product ratio found an increased incidence of complications with higher plasma: red blood cell ratios. Advanced age among geriatric patients is associated with increased mortality and complications when undergoing MTP. Shock Index and age x Shock Index are accurate and reliable predictors of mortality and need for MTP in the geriatric trauma population with hemorrhagic shock suffering blunt and/or penetrating injuries. An increased plasma: RBC ratio was associated with more complications in geriatric patients.

Whole blood: Total blood product ratio impacts survival in injured children.

Some studies in both children and adults have shown a mortality benefit for the use of low titer group O whole blood (LTOWB) compared with component therapy for traumatic resuscitation. Although LTOWB is not widely available at pediatric trauma centers, its use is increasing. We hypothesized that in children who received whole blood after injury, the proportion of whole blood in relation to the total blood product resuscitation volume would impact survival. The trauma database from a single academic pediatric Level I trauma center was queried for pediatric (age <18 years) recipients of LTOWB after injury (years 2015-2022). Weight-based blood product (LTOWB, red blood cells, plasma, and platelet) transfusion volumes during the first 24 hours of admission were recorded. The ratio of LTOWB to total transfusion volume was calculated. The primary outcome was in-hospital mortality. Multivariable logistic regression model adjusted for the following variables: age, sex, mechanism of injury, Injury Severity Score, shock index, and Glasgow Coma Scale score. Adjusted odds ratio representing the change in the odds of mortality by a 10% increase in the LTOWB/total transfusion volume ratio was reported. There were 95 pediatric LTOWB recipients included in the analysis, with median (interquartile range [IQR]) age of 10 years (5-14 years), 58% male, median (IQR) Injury Severity Score of 26 (17-35), 25% penetrating mechanism. The median (IQR) volume of LTOWB transfused was 17 mL/kg (15-35 mL/kg). Low titer group O whole blood comprised a median (IQR) of 59% (33-100%) of the total blood product resuscitation. Among patients who received LTOWB, there was a 38% decrease in in-hospital mortality for each 10% increase in the proportion of WB within total transfusion volume ( p < 0.001) after adjusting for age, sex, mechanism of injury, Injury Severity Score, shock index, and Glasgow Coma Scale score. Increased proportions of LTOWB within the total blood product resuscitation was independently associated with survival in injured children. Based on existing data that suggests safety and improved outcomes with whole blood, consideration may be given to increasing the use of LTOWB over CT resuscitation in pediatric trauma resuscitation. Therapeutic/Care Management; Level III.

Massive Transfusion in Pediatric Patients on Extracorporeal Membrane Oxygenation: A Secondary Analysis of the Massive Transfusion in Children (MATIC) Study.

Few data describe pediatric patients who receive massive transfusion for life-threatening hemorrhage (LTH) while on extracorporeal membrane oxygenation (ECMO). We present a retrospective secondary analysis of a multicenter prospective observational study to describe resource utilization and mortality in pediatric patients with LTH while on ECMO. Children who were on ECMO during an LTH were compared to children with LTH who were not on ECMO. Primary outcomes were volumes of blood products administered and 28 day mortality. Comparisons were assessed by two-sided Fisher's exact test or Wilcoxon rank sum test. A total of 449 children, including 36 on ECMO, were included. Compared to those not on ECMO, children on ECMO received a higher volume of blood products (110 [50-223] vs . 59 [28-113]) ml/kg, p = 0.002) and were more likely to receive antifibrinolytic therapy (39% vs . 10%, p < 0.001). Blood product ratios were similar. Extracorporeal membrane oxygenation patients had higher 28 day mortality (64% vs. 35%, p = 0.001), although 24 hour mortality was similar (17% vs . 23%, p = 0.5). In conclusion, children on ECMO with LTH experience high resource utilization and 28 day mortality. Studies are needed to identify children at risk for LTH and to evaluate ECMO-specific treatment strategies.

Increased platelet to red blood cell transfusion ratio associated with acute kidney injury in children with life-threatening bleeding.

Transfusion may increase the risk of organ failure through immunomodulatory effects. The primary objective of this study was to assess for patient or transfusion-related factors that are independently associated with the risk of acute kidney injury (AKI) and acute respiratory distress syndrome (ARDS) in a cohort of children with life-threatening bleeding from all etiologies. In a secondary analysis of the prospective observational massive transfusion in children (MATIC) study, multivariable logistic regression was performed in an adjusted analysis to determine if blood product ratios or deficits were independently associated with AKI or ARDS in children with life-threatening bleeding. There were 449 children included with a median (interquartile range, IQR) age of 7.3 years (1.7-14.7). Within 5 days of the life-threatening bleeding event, AKI occurred in 18.5% and ARDS occurred in 20.3% of the subjects. Every 10% increase in the platelet to red blood cell transfusion ratio is independently associated with a 12.7% increase in the odds of AKI (adjusted odds ratio 1.127; 95% confidence interval 1.025-1.239; p-value .013). Subjects with operative or medical etiologies were independently associated with an increased risk of AKI compared to those with traumatic injury. No transfusion-related variables were independently associated with the risk of developing ARDS. The use of increased platelet to red blood cell transfusion ratios in children with life-threatening bleeding of any etiology may increase the risk of AKI but not ARDS. Prospective trials are needed to determine if increased platelet use in this cohort increases the risk of AKI to examine possible mechanisms.

Higher Doses of Calcium Associated With Survival in Trauma Patients

IntroductionCalcium is required for coagulation, cardiac output, and peripheral vascular resistance. Between 85% and 94% of trauma patients treated with massive blood transfusion develop hypocalcemia.1 The aim of this study is to evaluate the relationship between increased intravenous calcium administration during massive transfusion and improved survival of trauma patients. MethodsWe performed a retrospective analysis of trauma patients who received massive transfusion over a 2-y period. Doses of elemental calcium administered per unit of blood product transfused were calculated by calcium to blood product ratio (CBR). Chi-square test evaluated association between coagulopathy and 30-d mortality. Two-sample t-test evaluated association between CBR and coagulopathy. Bivariate regression analysis evaluated association between CBR and blood products transfused per patient. Multivariable logistic regression analysis, controlling for age, sex, coagulopathy, and Injury Severity Score evaluated the association between CBR and mortality. ResultsThe study included 77 patients. Coagulopathy was associated with increased 30-d mortality (P < 0.05). Patients who survived had higher CBR than those who died (P < 0.05). CBR was associated with a significant reduction in total blood products transfused per patient (P < 0.05). CBR was not associated with coagulopathy (P = 0.24). Multivariable logistic regression analysis demonstrated that Injury Severity Score ≥16, coagulopathy and decreased CBR were significant predictors of mortality (P < 0.05). CBR above 50 mg was a predictor of survival (P < 0.05). ConclusionsHigher doses of calcium given per blood product transfused were associated with improved 30-d survival and decreased blood product transfusions.

Outcome of 1:1:1 Transfusion Ratio of Blood Products in Critical Bleeders Either Traumatic, Medical or Surgical

Outcome of 1:1:1 Transfusion Ratio of Blood Products in Critical Bleeders Either Traumatic, Medical or Surgical

Did interventions in a massive transfusion protocol program change transfusion practice?

Abstract Current literature supports improved clinical outcomes in the setting of trauma when a Massive Transfusion Protocol (MTP) adheres to transfusion at, or close, to a 1:1 ratio (RBC:Plasma). At our institution, between 2008 and 2015, the number of MTP activations increased ten-fold, accompanied by increased wastage of blood products and stress on the transfusion service. In response, in 2016-2018, we undertook an extensive root-cause analysis, and deployed multiple interventions, including clinician education and multiple process changes to the MTP, which succeeded in reining in inappropriate activation of the MTP, as we have previously published. Heretofore, we have not addressed whether these interventions also affected the ratio of blood products transfused during MTPs activated at our institution. Here, we test the hypothesis that the changes deployed in 2016-2018 were associated with improved adherence to the desired 1:1 ratio. The study is a retrospective analysis of massive transfusion data collected from 2008 to 2022. We reviewed RBC and Plasma units transfused to all patients receiving blood products through the MTP during this period. All patients transfused seven or more RBC and/or Plasma units following MTP activation were included in the study (total n = 443). Activations were classified by year. For each patient, the (RBC:Plasma) ratio transfused was calculated and assessed for adherence to a 1:1 ratio, with a ratio of 2:1 or greater classified as “suboptimal”. Our institution does not use Whole Blood. MTP usage at our institution gradually increased from 2008, when the MTP was established, to 2016, when the MTP procedure was revised. Suboptimal transfusion ratios (RBC:Plasma) also increased from 2008-2016. Between 2008 and 2013, 15% of patients received suboptimal ratios following MTP activation. In 2014-2016, suboptimal ratios were observed in 25% of MTPs. Following multiple interventions, the frequency of MTP activation dropped precipitously, as described, and was accompanied by a decrease in the percentage of suboptimal ratios; in 2020 to 2022, 11% of MTPs involving seven or more transfused units had a suboptimal ratio. In summary, the dramatic increase in activations of the MTP observed between 2008 and 2016 at our medical center was accompanied by an increase in suboptimal RBC:Plasma transfusion ratios. Interventions deployed between 2016 and 2018 led not only to reduced blood wastage, and lower stress of BB staff, but also to improved adherence to best transfusion practices, in the form of appropriate (RBC:Plasma) ratios transfused during MTPs.

Implementation of a hospital-wide massive transfusion protocol at a tertiary cancer center.

440 Background: Massive Transfusion Protocol (MTP) is a term used to describe a process to deliver blood products rapidly to treat life-threatening hemorrhage. MTPs follow a prescribed algorithm to efficiently replace blood products in set ratios. Three components of MTP include immediate availability of blood products, set types and ratios of blood products, and standardized roles for health care providers. MTP is associated with decreased morbidity and mortality compared to provider-driven decisions on blood transfusion. Methods: The Quality Improvement Assessment Board approved this initiative to standardize and create an MTP process outside of the Operating Room (OR). We assembled a multidisciplinary team to review and adopt evidence-based practices for MTP. A core group of content experts developed the relevant policy and protocol for activation and use of MTP in the Intensive Care Unit (ICU), Pediatric Intensive Care Unit (PICU), Emergency Room (ER), Interventional Radiology (IR) and inpatient floor. Simulations were held in these areas and Plan Do Study Act (PDSA) cycles used to improve the processes. Improvements included adjustment to the quantity and type of emergency release products immediately available, the timing of when platelets were delivered to providers and development of a ‘pull’ process for the Blood Bank to prepare additional blood products minimizing wastage. Following these changes, the MTP process became consistent and could be activated from all of the targeted locations. Each MTP episode was reviewed for outcomes and efficiency metrics. We held multidisciplinary care debriefings to review hemorrhagic events for areas of improvement. The OR had an existing process that was separate from this initiative, but will be aligned June 2023 and included in future analysis. Results: Baseline, from January 2022 to September 2022, 32 massive transfusion events occurred (3.5 per month). After implementation of the MTP protocol, from October 2022 to May 2023, the MTP protocol was activated 36 times (4.5 per month). There were 7 (22%) deaths at baseline and 5 (14%) after implementation. The average length of time from activation to receipt of first blood product was 26 minutes at baseline and 25 minutes with MTP. The average number of units administered at baseline included 7.7 units of red blood cells (RBC), 7.6 units fresh frozen plasma (FFP), 1 unit single donor platelets, and 2 units cryoprecipitate compared to after implementation of 6.9 units RBC, 6 units FFP, 1.6 units single donor platelets, and 3 units cryoprecipitate. The ICU was the most common MTP activation location (44%), followed by ER (19%), PICU (17%), the floor (14%) and IR (6%). Conclusions: It is feasible and safe to deploy an MTP throughout an institution. Preliminary data show a decrease in the percentage of patient deaths with use of MTP. Additional analysis are planned to evaluate the incremental improvements made with each PDSA cycle.

Who are the trauma team leaders across Canada? A national survey evaluating the profession in adult and pediatric level one trauma centres.

Trauma Team Leaders (TTLs) are critical for coordinating and leading trauma resuscitations. This survey sought to characterize the demographics and professional practices of Canadian TTLs at level one trauma centres. As a secondary objective, this information will be utilized to inform the operational goals of the Trauma Association of Canada (TAC) TTL Committee. A detailed survey, developed by the TAC board of directors and TTL committee leads, was sent to 225 TTLs across Canada's level one trauma centres. TTLs were identified via contacting trauma directors at each level one centre, in addition to public registry searches. This survey captured demographics, professional background, resuscitation practices, trauma team composition, and TTL involvement in trauma responses. The response rate was 41.7%. Mean respondent age was 42 (SD 7.4) and 71.0% were male. Most TTLs trained in emergency medicine (53.1%) or general surgery (25.5%); 63.8% underwent TTL training: either via a trauma surgery fellowship or TTL fellowship. All centres have a massive hemorrhage protocol implemented, and there is no large variation between the rates of use of cryoprecipitate and fibrinogen, nor the ratio of blood products transfused (2:1 vs 1:1). Most TTL respondents intend to participate in a TTL group associated with TAC (85.1%). The results of this survey will contribute to the recognition of TTLs as a crucial role in the initial phase of care of severely injured trauma patients and serves as the first publication to document professional backgrounds and practices of Canadian TTLs at level one trauma centres. All the information gathered via this survey will be used by the TAC TTL Committee, which will focus on several initiatives such as the dissemination of best practice guidelines and creation of a TTL stream at the TAC Annual Conference.

1210 Network Meta-Analysis of Associated Mortality with Transfusion Strategies for Major Haemorrhage in Adults

Abstract Aim The aetiology of a large proportion of mortality in trauma patients is attributed to acute major haemorrhage. Damage control resuscitation and surgery have been developed as part of management, which often includes large volume blood product transfusion. The aim of this meta-analysis was to investigate differences in mortality between transfusion strategies used in major haemorrhage in adults (18+ years). Method A frequentist random effects network meta-analysis (NMA) using the netmeta package in R 4.0.5 of the eligible papers in the systematic review “Optimal dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a systematic review” compared a 1:1:1 ratio of red blood cells (RBC), fresh frozen plasma (FFP) and platelets (P) to a ratio of 2:1:1, whole blood, and laboratory-guided replacement. Homogeneity and heterogeneity were assessed with Cochran’s Q. Results Mortality at one month by group was 21.8% (12/55) for whole blood, 17.0% (58/342) for 2RBC:1FFP:1P, 14.3% (5/35) for laboratory-guided transfusion and 22.3% (96/43) for standard 1RBC:1FFP:1P ratio. The NMA showed no significant differences between groups, with relative risk of death when compared to 1RBC:1FFP:1P by one month of 1.42 (0.631; 3.19, p = 0.398) for whole blood, 0.7643 (0.562; 1.04, p = 0.0871) for 2RBC:1FFP:1P and 0.4396 (0.1741; 1.1099, p = 0.0820) for laboratory-guided transfusion. Conclusions The results demonstrated no significant differences in mortality between transfusion strategies in major haemorrhage - however, some arms of the NMA contain few patients and so may be underpowered to detect differences between groups. On this evidence, current use of component therapy is not inferior to another transfusion strategy.

Haemostatic resuscitation in practice: a descriptive analysis of blood products administered during Operation HERRICK, Afghanistan

IntroductionLife-threatening haemorrhage is the leading cause of potentially survivable injury in battlefield casualties. During Operation HERRICK (Afghanistan), mortality rates improved year on year due to a number of advances in...

Ultramassive Transfusion for Trauma in the Age of Hemostatic Resuscitation: A Retrospective Single-Center Cohort From a Large US Level-1 Trauma Center, 2011-2021.

Uncontrolled bleeding is a leading cause of death in trauma. In the last 40 years, ultramassive transfusion (UMT; ≥20 units of red blood cells [RBCs]/24 hours) for trauma has been associated with 50% to 80% mortality; the question remains as to whether the increasing number of units transfused in urgent resuscitation is a marker of futility. We asked whether the frequency and outcomes of UMT have changed in the era of hemostatic resuscitation. We performed a retrospective cohort study of all UMTs in the first 24 hours of care over an 11-year period at a major US level-1 adult and pediatric trauma center. UMT patients were identified, and a dataset was built by linking blood bank and trauma registry data, then reviewing individual electronic health records. Success in achieving hemostatic proportions of blood products was estimated as (units of plasma + apheresis-platelets-in-plasma + cryoprecipitate-pools + whole blood]/[all units given] ≥0.5. Demographics, injury type (blunt or penetrating), severity (Injury Severity Score [ISS]), severity pattern (Abbreviated Injury Scale score for head [AIS-Head] ≥4), admitting laboratory, transfusion, selected emergency department interventions, and discharge status were assessed using χ2 tests of categorical association, the Student t-test of means, and multivariable logistic regression. P <.05 was considered significant. Among 66,734 trauma admissions from April 6, 2011 to December 31, 2021, we identified 6288 (9.4%) who received any blood products in the first 24 hours, 159 of whom received UMT (0.23%; 154 aged 18-90 + 5 aged 9-17), 81% in hemostatic proportions. Overall mortality was 65% (n = 103); mean ISS = 40; median time to death, 6.1 hours. In univariate analyses, death was not associated with age, sex, or more RBC units transfused beyond 20 but was associated with blunt injury, increasing injury severity, severe head injury, and failure to receive hemostatic blood product ratios. Mortality was also associated with decreased pH and evidence of coagulopathy at admission, especially hypofibrinogenemia. Multivariable logistic regression showed severe head injury, admission hypofibrinogenemia and not receiving a hemostatic resuscitation proportion of blood products as independently associated with death. One in 420 acute trauma patients at our center received UMT, a historically low rate. A third of these patients lived, and UMT was not itself a marker of futility. Early identification of coagulopathy was possible, and failure to give blood components in hemostatic ratios was associated with excess mortality.

Association of blood product ratios with early mortality in pediatric trauma resuscitation: A time-dependent analysis from the National Trauma Databank.

Injured children with severe hemorrhage often receive blood product transfusions with ratios of plasma and platelets to packed red blood cells (PRBCs) approaching 1:1:1. Whether blood product ratios vary during pediatric resuscitation is unknown. This study (1) described precise timing of pediatric blood product administration, (2) characterized changes in blood product ratios over time, and (3) evaluated the association of blood products with early mortality while incorporating time-varying factors. Pediatric (younger than 18 years) trauma patients receiving high-volume transfusion (>40 mL/kg total products or >2 U PRBC or whole blood, during first 4 hours) were obtained from the 2017 to 2019 Trauma Quality Improvement Program database. The time of each individual product transfusion was recorded, along with demographics, injury details, and times of death. Patients were assigned to blood product groups at 15-minute intervals: high plasma/PRBC ratio (>1:1) with platelets, high plasma/PRBC ratio (>1:1) without platelets, low plasma/PRBC ratio (<1:1), PRBC only, and whole blood. Cox proportional hazards modeling for 24-hour mortality was performed, including blood product group as a time-varying variable and adjusting for relevant covariates. Of 1,152 included patients (median age, 15 years; 32% penetrating, 28% severe traumatic brain injury [sTBI]), 18% died within 24 hours. During the resuscitation period, the number of patients in high-ratio groups increased over time, and patients switched blood product groups up to six times. There was no significant difference in mortality by blood product group. Among patients with sTBI, there was a strong trend toward lower mortality among high plasma/PRBC without platelets versus high plasma/PRBC with platelets (hazard ratio, 0.55; p = 0.07). No significant association of high ratios or whole blood with mortality was seen when time-varying factors were incorporated. The impact of balanced resuscitation strategies, particularly platelet transfusion, may be greatest among patients with sTBI. Optimizing balanced resuscitation for children requires appropriately designed prospective studies. Therapeutic/Care Management; Level IV.

A narrative review of damage control resuscitation for paediatric trauma patients in Iraq and Afghanistan from 2001 to 2016

Introduction Requirement for blood transfusion in the injured paediatric civilian population is rare. Therefore, a substantial evidence base underpinning damage control resuscitation (DCR) in paediatric patients is lacking. Published outcome data originating from Iraq and Afghanistan offer a unique opportunity to study large cohorts of children who received DCR. It is hoped that by collating the data, this review will inform pre-deployment medical training and support the development of paediatric specific DCR guidelines, which can be used in all trauma environments. Methodology A comprehensive search of the literature was conducted using online databases, grey literature searching and screening of reference lists. Papers discussing blood product, crystalloid or tranexamic acid (TXA) administration in paediatric patients injured in Iraq and Afghanistan from 2001to present were included. Results Eighteen papers were included – all were retrospective studies of data from military trauma databases. Most children that received massive transfusion were male (73.4%), injured in Afghanistan (69.9%) by explosives (60.4%) with a median age of 9 years. A definition of paediatric massive transfusion of 40 ml/kg of all blood products within 24 h was developed. Massive transfusion rates were high (15.7% of children). Whole blood administration occurred in 4% of patients requiring blood transfusions. Low crystalloid volumes in combination with balanced blood product ratios were associated with improved survival, along with the use of whole blood and TXA. Conclusion The review offers insight into the paediatric population likely to require DCR and the optimal DCR strategies to be used in their management.

Blood component ratios in children with non-traumatic life-threatening bleeding.

In paediatric trauma patients, there are limited prospective data regarding blood components and mortality, with some literature suggesting decreased mortality with high ratios of plasma and platelets to red blood cells (RBCs) in massive transfusions; however, most paediatric massive transfusions occur for non-traumatic aetiologies and few studies assess blood product ratios in these children. This study's objective was to evaluate whether high blood product ratios or low deficits conferred a survival benefit in children with non-traumatic life-threatening bleeding. This is a secondary analysis of the five-year, multicentre, prospective, observational massive transfusion epidemiology and outcomes in children study of children with life-threatening bleeding from US, Canadian and Italian medical centres. Primary interventions were plasma:RBC and platelets:RBC (high ratio ≥1:2 ml/kg) and plasma and platelet deficits. The primary outcome was mortality at 6 h, 24 h and 28 days. Multivariate logistic regression models were used to determine independent associations with mortality. A total of 222 children were included from 24 medical centres: 145 children (median [interquartile range] age 2.1 years [0.3-11.8]) with operative bleeding and 77 (8.0 years [1.2-14.7]) with medical bleeding. In adjusted analyses, neither blood product ratios nor deficits were associated with mortality at 6 h, 24 h or 28 days. This paper addresses a lack of prospective data in children regarding optimal empiric massive transfusion strategies in non-traumatic massive haemorrhage and in finding no decrease in mortality with high plasma or platelet to RBC ratios or lower deficits supports an exploratory analysis for mortality.

Blood Lost: A Retrospective Review of Blood Wastage from a Massive Transfusion Protocol in a Tertiary Paediatric Hospital.

The paediatric massive transfusion protocol (MTP) is activated in the paediatric population for both trauma and non-trauma related indications. While it helps to improve the efficiency and efficacy of the delivery of blood products, it can also result in increased wastage. We aimed to evaluate the wastage rates from our paediatric MTP activations from 2013 to 2018. As part of an audit, we retrospectively reviewed the records of the paediatric patients who had MTP activations. We collected the following data: reason for MTP activation, weight of patient, number of cycles of MTP required, blood products used, blood products wasted, deviation from our institution's recommended MTP blood product ratio, and reason for wastage. We had 26 paediatric MTP activations within the audit period. There was an overall wastage rate of 1.5%, with wastage occurring in 3 out of 26 patients. The reason for all wastage was demise of the patient. Most patients' transfusion ratios deviated from our institution's MTP protocol. Our wastage rates are low likely because of clear MTP activation guidelines and a flexible MTP workflow.

Risk Factors Associated with Receiving Nonbalanced Massive Transfusion Protocol

INTRODUCTION: Implementation of massive transfusion protocol (MTP) with balanced blood product ratios results in improved mortality rates in trauma patients. However, compliance with MTP is still not universal. Our study investigated the risk factors for receiving nonbalanced MTP (NBMTP). METHODS: We retrospectively reviewed trauma patients who received massive transfusion, defined as at least 10 units of packed red blood cells within 24 hours of admission, using the American College of Surgeons TQIP database between 2016 and 2019. Demographics, comorbidities, prehospitalization data, hospital characteristics, injury-related variables, transfusions, and clinical outcomes were abstracted. Patients who received balanced MTP (BMTP), defined as blood products transfused in a 1:1 to 1:2 ratio of fresh frozen plasma to packed red blood cells, were compared with patients who received NBMTP. Risk factors for receiving NBMTP were analyzed by Student’s t-test and chi-square test. Multivariate logistic regression was used as required. RESULTS: A total of 15,435 patients who received massive transfusions were included. Of these, 71% patients received BMTP, and 29% patients received NBMTP. Patients who received BMTP had significantly longer emergency medical services transit times to hospital (87.5 vs 99.2, p = 0.03), had a higher Injury Severity Score (32.4 vs 31.5, p = 0.001), and received more units of packed red blood cells (22.0 vs 19.6, p < 0.001). Logistic regression identified admission to Level II trauma centers (odds ratio 1.20, 95% CI 1.07 to 1.34) and lower Injury Severity Score (odds ratio 0.995, 95% CI 0.992 to 0.998) as independent risk factors for receiving NBMTP. CONCLUSION: Trauma patients at Level II trauma centers or who had lower Injury Severity Scores were less likely to receive BMTP. Clinicians should be mindful of this predisposition for decreased compliance with BMTP in these patients and institutions.