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Mechanism, frequency, transfusion and outcome of severe trauma in coagulopathic paediatric patients.

ABSTRACT: PURPOSE:Acute traumatic coagulopathy can result in uncontrolled haemorrhage responsible for the majority of early deaths after adult trauma. Data on the frequency, transfusion practice and outcome of severe trauma haemorrhage in paediatric patients are inconsistent. METHODS:Datasets from paediatric trauma patients were retrieved from the registry of the German trauma society (TR-DGU®) between 2009 and 2016. Coagulopathy was defined by a Quick's value??1.4) and/or thrombocytes???100 k upon emergency room admission. Children were grouped according to age in 4 different groups (A: 1-5, B: 6-10, C: 11-15 and D: 16-17 years). Prevalence of coagulopathy was assessed. Demographics, injury severity, haemostatic management including transfusions and mortality were described. RESULTS:5351 primary admitted children???17 years with an abbreviated injury scale (AIS)???3 and complete datasets were included. The prevalence of coagulopathy was 13.7% (733/5351). The majority of the children sustained blunt trauma (more than 90% independent of age group) and a combination of traumatic brain injury (TBI) and any other trauma in more than 60% (A, C, D) and in 53.8% in group B. Coagulopathy occurred the most among the youngest (A: 18.2%), followed by all other age groups with approximately 13%. Overall mortality was the highest in the youngest (A: 40.9%) and among the youngest patients with traumatic brain injury (A: 71.4% and B: 47.1%). Transfusion of packed red blood cells (pRBCs) and fresh frozen plasma (FFPs) occurred almost in a 2:1 ratio (or less) across all age subgroups. CONCLUSION:Traumatic haemorrhage in association with coagulopathy and severe shock is a major challenge in paediatric trauma across all age groups.

SUBMITTER: Driessen A

PROVIDER: S-EPMC7245642 | biostudies-literature | 2020 May

REPOSITORIES: biostudies-literature

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Mechanism, frequency, transfusion and outcome of severe trauma in coagulopathic paediatric patients.

Driessen Arne A Wafaisade Arasch A Lefering Rolf R Migliorini Filippo F Fröhlich Matthias M Arbab Dariusch D Maegele Marc M Mutschler Manuel M

European journal of trauma and emergency surgery : official publication of the European Trauma Society 20200524 1

<h4>Purpose</h4>Acute traumatic coagulopathy can result in uncontrolled haemorrhage responsible for the majority of early deaths after adult trauma. Data on the frequency, transfusion practice and outcome of severe trauma haemorrhage in paediatric patients are inconsistent.<h4>Methods</h4>Datasets from paediatric trauma patients were retrieved from the registry of the German trauma society (TR-DGU<sup>®</sup>) between 2009 and 2016. Coagulopathy was defined by a Quick's value < 70% (INR (interna ...[more]

PMID: 32448940

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Project description:BackgroundHemorrhage coupled with coagulopathy remains the leading cause of preventable in-hospital deaths among trauma patients. Use of a transfusion protocol with a predefined ratio of 1:1:1 (1 each of red blood cells [RBC], frozen plasma [FP] and platelets) has been associated with improved survival in retrospective studies in military and civilian settings, but such a protocol has its challenges and may increase the risk of respiratory complications. We conducted a randomized controlled trial to assess the feasibility of a 1:1:1 transfusion protocol and its effect on mortality and complications among patients with severe trauma.MethodsWe included 78 patients seen in a tertiary trauma centre between July 2009 and October 2011 who had hypotension and bleeding and were expected to need massive transfusion (≥ 10 RBC units in 24 h). We randomly assigned them to either the fixed-ratio (1:1:1) transfusion protocol (n = 40) or to a laboratory-results-guided transfusion protocol (control; n = 38). The primary outcome, feasibility, was assessed in terms of blood product ratios and plasma wastage. Safety was measured based on 28-day mortality and survival free of acute respiratory distress syndrome.ResultsOverall, a transfusion ratio of 1:1:1 was achieved in 57% (21/37) of patients in the fixed-ratio group, as compared with 6% (2/32) in the control group. A ratio of 1:1 (RBC:FP) was achieved in 73% (27/37) in the fixed-ratio group and 22% (7/32) in the control group. Plasma wastage was higher with the intervention protocol (22% [86/390] of FP units v. 10% [30/289] in the control group). The 28-day mortality and number of days free of acute respiratory distress syndrome were statistically similar between the groups.InterpretationThe fixed-ratio transfusion protocol was feasible in our study, but it was associated with increased plasma wastage. Larger randomized trials are needed to evaluate the efficacy of such a protocol in trauma care.Trial registrationClinicalTrials.gov, no. NCT00945542.

Project description:BackgroundBoth groups A and AB plasma have been approved for emergency-release transfusion in acutely bleeding trauma patients before blood grouping being performed. The safety profile associated with this practice has not been well characterized, particularly in patients requiring massive transfusion.MethodsThis secondary analysis of the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios trial examined whether exposure to group A emergency-release plasma (ERP) was noninferior to group AB ERP. We also examined patients whose blood groups were compatible with group A ERP versus patients whose blood groups were incompatible with group A ERP. Outcomes included 30-day mortality and complication rates including systemic inflammatory response syndrome, infection, renal injury, pulmonary dysfunction, and thromboembolism.ResultsOf the 680 patients predicted to receive a massive transfusion, 584 (85.9%) received at least 1 U of ERP. Of the 584 patients analyzed, 462 (79.1%) received group AB and 122 (20.9%) received group A ERP. Using a hazard ratio (HR) of 1.35 as the noninferiority margin, transfusion with group A versus group AB ERP was not associated with increased thromboembolic rates (HR, 0.52; 95% confidence interval [CI], 0.31-0.90). Mortality (HR, 1.15; 95% CI, 0.91-1.45) and nonfatal complication rates (HR, 1.24; 95% CI, 0.87-1.77) were inconclusive. In the subgroup analysis, transfusion with incompatible ERP (group B or AB patients receiving group A ERP) was not associated with increased nonfatal complications (HR, 1.02; 95% CI, 0.80-1.30). There were no reported hemolytic transfusion reactions.ConclusionThe use of ERP is common in patients requiring massive transfusion and facilitates the rapid balanced resuscitation of patients who have sustained blood loss. Group A ERP is an acceptable option for patients requiring massive transfusion, especially if group AB ERP is not readily available.Level of evidenceTherapeutic/Care Management, level IV; Prognostic, level III.

Project description:IntroductionTrauma causes 40% of child deaths in high-income countries, with haemorrhage being a leading contributor to death in this population. There is a growing recognition that fibrinogen and platelets play a major role in trauma-induced coagulopathy (TIC) but the exact physiological mechanisms are poorly understood.Methods and analysisThis is a prospective multicentre, open-label, randomised, two-arm parallel feasibility study conducted in the emergency departments, intensive care units and operating theatres of participating hospitals. Severely injured children, aged between 3 months and 18 years, presenting with traumatic haemorrhage requiring transfusion of blood products will be screened for inclusion.Sixty-eight patients will be recruited and will be allocated to fibrinogen replacement using fibrinogen concentrate (FC) or cryoprecipitate in a 1:1 ratio. Fibrinogen replacement will be administered to patients with a FIBTEM A5 of ≤10. All other aspects of the currently used rotational thromboelastometry-guided treatment algorithm and damage-control approach to trauma remain the same in both groups.The primary outcome is time to administration of fibrinogen replacement from time of identification of hypofibrinogenaemia. Clinical secondary outcomes and feasibility outcomes will also be analysed.Ethics and disseminationThis study has received ethical clearance from the Children's Health Queensland Human Research Ethics Committee (HREC/17/QRCH/78). Equipment and consumables for sample testing have been provided to the study by Haemoview Diagnostics, Werfen Australia and Haemonetics Australia. FC has been provided by CSL Behring, Australia. The funding bodies and industry partners have had no input into the design of the study, and will not be involved in the preparation or submission of the manuscript for publication.The use of viscoelastic haemostatic assays and early fibrinogen replacement has the potential to improve outcomes in paediatric trauma through earlier recognition of TIC. This in turn may reduce transfusion volumes and downstream complications and reduce the reliance on donor blood products such as cryoprecipitate.The use of FC has implications for regional and remote centres who would not routinely have access to cryoprecipitate but could store FC easily. Access to early fibrinogen replacement in these centres could make a significant impact and assist in closing the gap in trauma care available to residents of these communities.Outcomes of this study will be submitted for publication in peer-reviewed journals and submitted for presentation at national and international scientific fora.Trial registration numberNCT03508141.

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Mechanism, frequency, transfusion and outcome of severe trauma in coagulopathic paediatric patients.

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Mechanism, frequency, transfusion and outcome of severe trauma in coagulopathic paediatric patients.

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