BACKGROUND Pediatric patients require massive transfusion (MT) in a variety of settings. Multiple studies of adult MT support balanced ratio transfusion to improve outcomes; however, it is unclear if these findings can be extrapolated to pediatric populations. The use of balanced transfusion ratios, MT protocols, hemostatic adjuncts, and even the definition of a MT in children are all open questions. This review presents details of care from current practices in pediatric MT and summarizes practice strategies while providing insight from our single-center experience. METHODS PubMed, EMBASE, and Web of Science were searched using MeSH index and free-text terms for articles from 1946 to 2017. Articles were independently reviewed by two reviewers. Studies were assessed for definition of MT, factors predicting MT, MT complications, blood product ratios, hemostatic adjuncts, protocol logistics, and clinical outcomes. RESULTS A heterogeneous composite of 29 articles was included in the analysis. Of these, 45% reported a formal transfusion protocol or adopted one during the study. Seven unique definitions of pediatric MT were reported; the most common was >1 total blood volume within 24 hours. A total of 18,369 patients were assessed, and 1,163 received MT (6.3%). Overall mortality for patients requiring MT in studies reporting mortality was high (range 14.7% to 51.2%). We identified 14 patients receiving MT at our center with an age range of 8 months to 18 years and average transfusion of 38.1 mL/kg red blood cells (range: 22.1 mL/kg to 156.7 mL/kg). CONCLUSIONS Current practices of pediatric MT demonstrate a variety of site-specific interventions with a persistently high mortality rate. A national focus on improving techniques of MT in children has the potential to save the lives of these children. LEVEL OF EVIDENCE Systematic review, levels IV and V.

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Thousands of children experience a cardiac arrest event in the hospital each year, with more than half of these patients not surviving to hospital discharge. Cardiopulmonary resuscitation (CPR) depth, rate, velocity and percentage of high-quality chest compressions are modifiable factors associated with improved survival. Therefore, we created a novel and standardised process to track and analyse cardiac arrests in the Duke paediatric intensive care unit (PICU). Our aim was to identify areas for improved American Heart Association (AHA) compliance and implement education and communication-based initiatives to enhance early recognition of at-risk patients leading to improved outcomes. From January 2017 to December 2018, all cardiac arrests in our PICU were tracked, reviewed and presented at monthly morbidity and mortality conference. We used the data to track compliance with AHA guidelines and identify opportunities for improvement. Through these efforts, we established a multidisciplinary cardiac arrest education and review programme. Over the 2-year period, we tracked 45 cardiac arrests, which comprised 2% of all PICU admissions. In 2017, during the first year of development, 16 of 22 arrests (73%) were not reported to code committee members in time for complete review. Of the six cardiac arrests with complete reviews, only 17% followed AHA guidelines. In 2018, all 23 arrest events were communicated and 76% of resuscitations were found to be compliant with AHA guidelines. Survival of patients to discharge was 47% in 2017 and increased to 63% in 2018 with similar percentage of PICU admissions having a cardiac arrest between the 2 years. The primary aim of this project was to establish a multidisciplinary comprehensive cardiac arrest review process. This programme allowed for comprehensive analysis of individual events, promoted quality improvement initiatives and improved consistent delivery of high-quality CPR.

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