While military and adult research has shown massive transfusion protocols to be lifesaving, implementation and validation in pediatrics lags.
When someone is critically injured with life-threatening bleeding, the primary objective of the care team is to stop the bleeding and replace the lost blood. Historically, children in this situation were administered red blood cells (RBCs) upon arrival to the emergency department, and doctors would wait for blood typing before further transfusions were initiated.
Now, the paradigm is shifting with massive transfusion protocols (MTPs) proving to be life-saving in military and adult studies. Massive transfusion protocols expedite the transfusion of plasma, platelets and RBCs in a 1:1:1 ratio by specifying the early delivery of blood products in predefined ratios until the patient is hemodynamically stable.
“MTPs are one way that a hospital can ensure that in the case of life threatening hemorrhage that patients are transfused properly,” says Julie Leonard, MD, MPH, pediatric emergency medicine subspecialist and associate director of the Center for Pediatric Trauma Research at Nationwide Children’s Hospital and senior author on the study.
While the adult literature shows a clear benefit to implementing MTPs, little research has been done in the pediatric population.
“In pediatric MTPs, we use the 1:1:1 ratio that has been shown to improve outcomes in adults,” says Dr. Leonard, who is also an associate professor of Pediatrics at The Ohio State University College of Medicine. “However, we don’t know if that is the optimal ratio for children. There’s just not enough research in children.”
Dr. Leonard and a team of physicians from Nationwide Children’s Hospital, Emory University and St. Louis Children’s Hospital have teamed up to look at MTPs in pediatric Level 1 trauma centers.
In a recent retrospective study, they looked at injured children less than 18 years old who presented to a Level 1 pediatric trauma center from May 1, 2005 to February 28, 2014. Over the nine years reviewed, 11,995 children presented for trauma management, 235 were transfused and met study eligibility criteria; 120 pre-MTP implementation and 115 post-MTP implementation.
In-hospital mortality and intensive care unit/ventilator/pressor-free days and Glasgow Outcome Score were tracked as primary and secondary outcomes. The team also investigated adherence to the MTP and overall blood product utilization.
One of the challenges institutions face with implementing MTPs is the concern about the impact on the blood bank and blood product usage. The study showed that concerns about the impact of MTPs on the blood supply are unfounded. The mean amount of blood product used in cases of MTP was not increased.
The analysis failed to show a significant improvement in overall outcome for the patients who had MTP activations and massive transfusions. The authors suggest that the small number of patients who actually received MTP transfusions may play a role in the lack of clear outcomes benefit. Additionally, they highlight the lack of research on the most effective ratio of plasma, platelets, and red blood cells in pediatric patients.
“We showed that MTP implementation increases plasma and PLT to RBC ratios, reduces plasma and PLT deficits and decreased time to first plasma administration for children that are transfused after injury,” says Dr. Leonard. “All of these factors are believed to improve management of hemorrhagic shock.”
The authors also note that all hemorrhagic deaths occurred before MTP implementation. “Numerous overlapping variables are at play here,” says Dr. Leonard.
More research is needed to address many questions facing pediatric institutions implementing MTPs. Dr. Leonard and her team hope to answer many of them through their upcoming study.
“We have recently received funding from the National Institutes of Health to begin a prospective study and registry for MTPs across medical centers,” says Dr. Leonard. “We hope that a larger multicenter trial will help us to answer the many remaining questions about how best to implement MTPs in pediatrics.”
Hwu RS, Sinella PC, Keller MS, Wallendorf M, Leonard JC. The effect of massive transfusion protocol implementation on pediatric trauma care. Transfusion. 2016 Aug 29. [Epub ahead of print]