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Multicenter study of crystalloid boluses and transfusion in pediatric trauma—When to go to blood?

Polites, Stephanie F. MD; Nygaard, Rachel M. PhD; Reddy, Pooja N. MS; Zielinski, Martin D. MD; Richardson, Chad J. MD; Elsbernd, Terri A. MSN; Petrun, Branden M. MD; Weinberg, Sean L. MD; Murphy, Sherrie BSN; Potter, Donald D. MD; Klinkner, Denise B. MD; Moir, Christopher R. MD

Journal of Trauma and Acute Care Surgery: July 2018 - Volume 85 - Issue 1 - p 108–112
doi: 10.1097/TA.0000000000001897
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BACKGROUND The 9th edition of Advanced Trauma Life Support 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 The 2010 to 2016 highest tier activation patients younger than 15 years 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) greater than 0.9 were included. Crystalloid boluses (20 ± 10 mL/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 (interquartile range) Injury Severity Score was 11 (6,25). Twenty-nine percent received one bolus, 17% received two, and 10% received at least three. Transfusion of any blood product occurred in 50 (24%) patients; mean (range) red blood cells was 23 (0–89) mL/kg, plasma 8 (0–69), and platelets 1 (0–18). The likelihood of transfusion increased logarithmically from 11% to 43% for those requiring 2 or more boluses (Fig. 1). This relationship persisted on multivariable analysis that adjusted for institution, age, and shock index with good discrimination (Area under the Receiver Operating Characteristic, 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 Therapeutic study, level IV.

From the Department of Surgery (S.F.P., P.N.R., M.D.Z., T.A.E., D.D.P., D.B.K., C.R.M.), Mayo Clinic, Rochester; Department of Surgery (R.M.N., C.J.R., B.M.P., S.M.), Hennepin County Medical Center, Minneapolis, MN.

Submitted: December 1, 2017, Revised: January 22, 2018, Accepted: February 27, 2018, Published online: March 14, 2018.

This article was presented at the 31st EAST Annual Scientific Assembly, January 9–13, 2018, in Lake Buena Vista, Florida.

Address for reprints: Stephanie F. Polites MD, MPH, Mayo Clinic 200 1st Street SW Rochester, MN 55905 (507) 284-2511; email: polites.stephanie@mayo.edu.

© 2018 Lippincott Williams & Wilkins, Inc.