The evolution of pediatric transfusion practice during combat operations 2001-2013.

Cannon JW, Neff LP, Pidcoke HF, Aden JK, Spinella PC, Johnson MA, Cap AP, Borgman MA

J Trauma Acute Care Surg. 2018 Mar 16. Epub ahead of print

BACKGROUND: Hemostatic resuscitation principles have significantly changed adult trauma resuscitation over the past decade. Practice patterns in pediatric resuscitation likely have changed as well; however, this evolution has not been quantified. We evaluated pediatric resuscitation practices over time within a combat trauma system.

METHODS: The Department of Defense Trauma Registry (DoDTR) was queried from 2001-2013 for pediatric patients (<18 years). Patients with burns, drowning, and missing injury severity score (ISS) were excluded. Volumes of crystalloid, packed red blood cells (PRBC), whole blood (WB), plasma (PLAS), and platelets (PLT) given in the first 24 hours were calculated per kg body weight. Tranexamic acid (TXA) use was also determined. Patients were divided into EARLY (2001-2005) and LATE (2006-2013) cohorts, and subgroups of transfused (TX+) and massively transfused (MT+) patients were created. ICU and hospital length of stay (LOS) and 24-hour and in-hospital mortality were compared.

RESULTS: 4,358 patients met inclusion criteria. Comparing EARLY vs. LATE, injuries from explosions, isolated or predominant head injuries, and ISS all increased. The proportion of TX+ patients also increased significantly (13.6% vs. 37.4%, p<0.001) as did the number of MT+ patients (2.1% vs. 15.5%, p<0.001). Transfusion of high PLAS:RBC and PLT:RBC ratios increased in both the TX+ and MT+ subgroups, although overall PLT and WB use was low. After adjusting for differences between groups, the odds of death was no different EARLY vs. LATE but decreased significantly in the MT+ patients with time as a continuous variable.

CONCLUSION: Transfusion practice in pediatric combat casualty care shifted towards a more hemostatic approach over time. All-cause mortality was low and remained stable overall and even decreased in MT+ patients despite more injuries due to explosions, more head injuries and greater injury severity. However, further study is required to determine the optimal resuscitation practices in critically injured children.

LEVEL OF EVIDENCE: Epidemiologic study, level IV.