Key Indicators Associated With Survival in Pediatric Trauma Massive Transfusion Protocol.

Introduction: Prior studies and scoring systems have been developed to optimize massive transfusion protocol (MTP) in adults, but an established protocol for children does not yet exist. This study aimed to evaluate the factors associated with survival in MTP activation among pediatric trauma patients.

Methods: Patients aged 18 y and under who received MTP were queried from the National Trauma Data Bank from 2017 to 2019, with MTP defined as receiving >40 mL/kg of blood products (e.g., red blood cells, plasma, and platelets) within 4 h of admission. Patients with fatal injuries and/or no signs of life on admission were excluded. Baseline characteristics and clinical outcomes were compared between patients who were discharged alive (DC-alive) and those who died (DC-deceased). Multivariable regression was performed to identify indicators predictive of survival and expressed in odds ratios (ORs) and 95% confidence intervals (CIs).

Results: Of 9115 patients who underwent transfusion, 947 (10.4%) required MTP and remained in the cohort. A total of 642 patients (68%) survived. Patients who survived were more likely to undergo hemorrhage control surgery (71% versus 40%, P < 0.001). No predominance of any combination of blood products transfused (e.g., red blood cells, plasma, and platelets) was observed between groups (P = 1.00). Factors associated with survival included tachycardia (OR 2.44, 95% CI 1.60-3.76) and presentation to level I pediatric trauma centers (OR 1.47, 95% CI 0.96-2.27). Poor prognostic factors for survival included hypothermia (OR 0.52, 95% CI 0.32-0.85), severe Glasgow coma score (GCS; OR 0.07, 95% CI 0.04-0.12), very severe injury severity score (ISS; OR 0.38, 95% CI 0.22-0.64), self-payment (OR 0.35, 95% CI 0.19-0.65), and >80 mL per kilogram (mL/kg) of transfused blood products (OR 0.56, 95% CI 0.37-0.85).

Conclusions: Tachycardia and pediatric-verified trauma centers appear to be protective in pediatric trauma MTP; decreased survival was associated with hypothermia, severe Glasgow coma score, very severe injury severity score, self-payment, and >80 mL/kg of transfused blood products. Prediction tools should identify patients who are most likely to benefit from MTP and alternative interventions for those unlikely to improve with MTP.