Multicenter study of crystalloid boluses and transfusion in pediatric trauma-when to go to blood?

Polites SF, Nygaard RM, Reddy PN, Zielinski MD, Richardson CJ, Elsbernd TA, Petrun BM, Weinberg SL, Murphy S, Potter DD, Klinkner DB, Moir CR.

J Trauma Acute Care Surg. 2018 Mar 12

BACKGROUND: The 9th edition of ATLS recommends up to three crystalloid boluses in pediatric trauma patients with consideration of transfusion after the second bolus however this approach is debated. We aimed to determine if requirement of more than one fluid bolus predicts the need for transfusion.

METHODS: 2010-2016 highest tier activation patients <15 years of age from two ACS Level I pediatric trauma centers were identified from prospectively maintained trauma databases. Those with a shock index (heart rate/systolic blood pressure) >0.9 were included. Crystalloid boluses (20±10 cc/kg) and transfusions administered prehospital and within 12 hours of hospital arrival were determined. Univariate and multivariable analyses were conducted to determine association between crystalloid volume and transfusion.

RESULTS: Among 208 patients, the mean age was 5±4 years (60% male), 91% sustained blunt injuries, and median (IQR) ISS was 11 (6,25). 29% received one bolus, 17% received two, and 10% received at least three. Transfusion of any blood product occurred in 50 (24%) patients; mean (range) RBC was 23 (0-89) cc/kg, plasma 8 (0-69), and platelets 1 (0,18). The likelihood of transfusion increased logarithmically from 11% to 43% for those requiring ≥2 boluses (Figure 1). This relationship persisted on multivariable analysis that adjusted for institution, age, and shock index with good discrimination (AUROC 0.84). Shock index was also strongly associated with transfusion.

CONCLUSION: Almost half of pediatric trauma patients with elevated shock index require transfusion following two crystalloid boluses and the odds of requiring a transfusion plateau at this point in resuscitation. This supports consideration of blood with the second bolus in conjunction with shock index though prospective studies are needed to confirm this and its impact on outcomes.

LEVEL OF EVIDENCE: III: Therapeutic.