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Development of transfusion guidelines for injured children using a Modified Delphi Consensus Process

Trappey, A. Francois III MD; Thompson, Kyle M. MD; Kuppermann, Nathan MD, MPH; Stephenson, Jacob T. MD; Nuno, Miriam A. PhD; Hewes, Hilary A. MD; Meyers, Sage R. MD, MSCE; Stanley, Rachel M. MD; Galante, Joseph M. MD; Nishijima, Daniel K. MD, MAS the Traumatic Injury Clinical Trial Evaluating Tranexamic Acid in Children (TIC-TOC) Collaborators of the Pediatric Emergency Care Applied Research Network (PECARN)

Journal of Trauma and Acute Care Surgery: October 2019 - Volume 87 - Issue 4 - p 935–943
doi: 10.1097/TA.0000000000002432

BACKGROUND There is wide variability of transfusion practices for children with hemorrhagic injuries across trauma centers. We are planning a multicenter, randomized clinical trial evaluating tranexamic acid in children with hemorrhage. Standardization of transfusion practices across sites is important to minimize confounding. Therefore, we sought to generate consensus-based transfusion guidelines for the trial.

METHODS We used a modified Delphi process utilizing a multi-site, multi-disciplinary panel of experts to develop our transfusion guidelines. A survey of 23 clinical categories on various aspects of transfusion practices was developed and distributed via SurveyMonkey®. Statements were graded on a 5-point Likert scale (“Strongly agree” to “This intervention may be harmful”). Statements were accepted if ≥ 80% of the panelists rated the statement as “Strongly agree” or “Agree”. After each round, the responses were calculated and the results included on subsequent rounds.

RESULTS 35 panelists from four pediatric trauma centers participated in the study, including 11 (31%) pediatric EM physicians, 8 (23%) pediatric trauma surgeons, 5 (14%) transfusionists, 5 (14%) pediatric anesthesiologists, and 6 (17%) pediatric critical care physicians (range of 8 to 10 from each clinical site). Four survey iterations were performed. In total 176 statements were rated and 39 were accepted by criteria across all 23 categories. An rational algorithm for transfusion in trauma was then developed.

CONCLUSIONS We successfully developed transfusion guidelines for various aspects of the management of children with hemorrhagic injuries using a modified Delphi process with broad interdisciplinary participation. We anticipate implementation of these guidelines will help minimize heterogeneity of transfusion practices across clinical sites for the upcoming clinical trial evaluating tranexamic acid in children with hemorrhage.

From the David Grant Air Force Medical Center (A.F.T.), Travis Air Force Base, Fairfield, California; Division of Trauma and Acute Care Surgery (A.F.T.), General Surgery Residency Program (K.M.T.), Department of Surgery, Emergency Medicine and Pediatrics (N.K.), UC Davis Health System, Division of Pediatric General and Thoracic Surgery (J.T.S.), Division of Public Health Sciences (M.A.N.), University of California at Davis, Davis, California; Division of Pediatric Emergency Medicine (H.A.H.), Primary Children's Hospital, University of Utah Health, Salt Lake City, Utah; Department of Emergency Medicine (S.R.M.), Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania; Emergency Medicine (R.M.S.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio; Department of Emergency Medicine, Trauma, Acute Care Surgery and Surgical Critical Care (J.M.G.), and Division of Emergency Medicine (D.K.N.), University of California at Davis, Davis, California.

Submitted: February 3, 2019, Revised: May 20, 2019, Accepted: June 11, 2019, Published online: July 9, 2019.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Address for reprints: Alfred Francois Trappey III, MD, Division of Trauma and Acute Care Surgery, University of California at Davis, 2315 Stockton Blvd, Sacramento, CA 95817; email:

Online date: July 10, 2019

© 2019 Lippincott Williams & Wilkins, Inc.