Blood component ratios in children with non‐traumatic life‐threatening bleeding

Abstract

Background and Objectives In paediatric trauma patients, there are limited prospective data regarding blood components and mortality, with some literature suggesting decreased mortality with high ratios of plasma and platelets to red blood cells (RBCs) in massive transfusions; however, most paediatric massive transfusions occur for non‐traumatic aetiologies and few studies assess blood product ratios in these children. This study's objective was to evaluate whether high blood product ratios or low deficits conferred a survival benefit in children with non‐traumatic life‐threatening bleeding. Materials and Methods This is a secondary analysis of the five‐year, multicentre, prospective, observational massive transfusion epidemiology and outcomes in children study of children with life‐threatening bleeding from US, Canadian and Italian medical centres. Primary interventions were plasma:RBC and platelets:RBC (high ratio ≥1:2 ml/kg) and plasma and platelet deficits. The primary outcome was mortality at 6 h, 24 h and 28 days. Multivariate logistic regression models were used to determine independent associations with mortality. Results A total of 222 children were included from 24 medical centres: 145 children (median [interquartile range] age 2.1 years [0.3–11.8]) with operative bleeding and 77 (8.0 years [1.2–14.7]) with medical bleeding. In adjusted analyses, neither blood product ratios nor deficits were associated with mortality at 6 h, 24 h or 28 days. Conclusion This paper addresses a lack of prospective data in children regarding optimal empiric massive transfusion strategies in non‐traumatic massive haemorrhage and in finding no decrease in mortality with high plasma or platelet to RBC ratios or lower deficits supports an exploratory analysis for mortality.

Epsilon aminocaproic acid is associated with acute kidney injury after life‐threatening hemorrhage in children

“…This may be explained by the heterogeneity in bleeding etiology among medical patients, smaller sample size, and the fact that medical etiology AKI risk by itself exceeded EACA‐associated risk in our population. Our findings are reflective of the broader literature available for medical bleeding in which the strategies that show survival benefit in trauma and surgical bleeding had limited reported benefit 39–42 . As the bleeding risks and coagulation profiles of medical patients are likely to be significantly different from operative and trauma patients, it is also possible that antifibrinolytic medications have different physiologic effects in this heterogenous population.…”

“…Our findings are reflective of the broader literature available for medical bleeding in which the strategies that show survival benefit in trauma and surgical bleeding had limited reported benefit. [39][40][41][42] As the bleeding risks and coagulation profiles of medical patients are likely to be significantly different from operative and trauma patients, it is also possible that antifibrinolytic medications have different physiologic effects in this heterogenous population. Large, multi-center studies in children with medical bleeding are needed to determine the efficacy and risk profile of antifibrinolytics in this population.…”

Increased platelet to red blood cell transfusion ratio associated with acute kidney injury in children with life‐threatening bleeding

“…The use of higher ratios in children for traumatic bleeding has become the standard of care, which is reflected in the design of an ongoing trial that is comparing blood components in a 1:1:1 ratio compared to low titer whole blood in children with life‐threatening traumatic bleeding 29 . In non‐trauma etiologies of life‐threatening bleeding, such as medical and operative causes, higher transfusion ratios or lower deficits of plasma and platelets to RBCs have not been associated with improved survival 12 . Therefore, in traumatic life‐threatening bleeding, if the use of hemostatic resuscitation principles with blood components does improve survival, then the risk of AKI can be accepted, with the goal of working towards reducing that risk.…”

“…29 In non-trauma etiologies of life-threatening bleeding, such as medical and operative causes, higher transfusion ratios or lower deficits of plasma and platelets to RBCs have not been associated with improved survival. 12 Therefore, in traumatic life-threatening bleeding, if the use of hemostatic resuscitation principles with blood components does improve survival, then the risk of AKI can be accepted, with the goal of working towards reducing that risk. In nontrauma patients with life-threatening bleeding, if there is no survival benefit and an increased risk of AKI with higher platelet to RBC transfusion ratios then the practice of using platelets liberally in this population needs to be reconsidered.…”

“…However, pediatric patients have many developmental differences from adult patients including their pathophysiologic response to severe bleeding, age-related maturation of the hemostatic system, and increased risk of head injury thus their response to transfusion strategies may vary compared to adults 1,10,11 ; it is necessary to develop pediatric-specific data. Further, recent data in children suggests that mortality and effectiveness of hemostatic resuscitation strategies depend on the etiology of bleeding, 4,12 though few studies include children with various causes of bleeding (operative, medical, traumatic).…”