Department of Anesthesia and Critical Care, University of Chicago, Chicago IL 60637, USA.
Curr Opin Anaesthesiol. 2018 Apr;31(2):201-206. doi: 10.1097/ACO.0000000000000569.
Trauma is the most common cause of pediatric mortality. Much of the research that led to life-saving interventions in adults, however, has not been replicated in the pediatric population. Children have important physiologic and anatomic differences from adults, which impact hemostasis and transfusion. Hemorrhage is a leading cause of death in trauma, and children have important differences in their coagulation profiles. Transfusion strategies, including the massive transfusion protocol and use of antifibrinolytics, are still controversial. In addition to the blood that is lost from the injury itself, trauma leads to inflammation and to a dysfunction in hemostasis, causing coagulopathy.
In one study in which children suffered from mainly blast and penetrating injuries in a combat setting (PEDTRAX trial), the early administration of tranexamic acid was associated with decreased mortality. Some authors suggest that this result may not apply to blunt trauma, which is much more common in children in noncombat settings. Using thromboelastography to guide the administration of recombinant Factor VIIa has been done in selected cases and may represent a future avenue of research.
This article explores new research from the past year in pediatric trauma, starting with the physiologic differences in pediatric red blood cells and coagulation profiles. We also looked at the dramatic change in thinking over the past decade in the tolerable level of anemia in critically ill pediatric patients, as well as scales for determining the need for massive transfusion and exploring if the concepts of damage control resuscitation apply to children. Other strategies, such as avoiding hypothermia, and the selective administration of antifibriniolytics, are important in pediatric trauma as well. Future research that is pediatric focused is needed for the optimal care of our youngest patients.
创伤是导致儿科患者死亡的最常见原因。然而，许多导致成人救生干预的研究并未在儿科人群中得到复制。儿童与成人在生理和解剖上有很大的不同，这会影响止血和输血。出血是创伤导致死亡的主要原因，儿童的凝血谱也有很大的差异。输血策略，包括大量输血方案和使用抗纤维蛋白溶解剂，仍然存在争议。除了因受伤本身而流失的血液外，创伤还会导致炎症和止血功能障碍，从而导致凝血功能障碍。
在一项主要针对战斗环境中儿童的爆炸和穿透性损伤的研究（PEDTRAX 试验）中，早期给予氨甲环酸与降低死亡率有关。一些作者认为，这一结果可能不适用于在非战斗环境中更为常见的钝性创伤。在一些选定的病例中，使用血栓弹性描记术来指导重组 VII 因子的给药已经完成，这可能代表了未来的研究方向。
本文探讨了过去一年中儿科创伤领域的新研究，首先是儿科红细胞和凝血谱的生理差异。我们还研究了过去十年中对危重症儿科患者可接受贫血水平的观念的巨大变化，以及确定大量输血需求的量表，并探讨了损伤控制性复苏的概念是否适用于儿童。避免低体温和选择性使用抗纤维蛋白溶解剂等其他策略在儿科创伤中也很重要。需要有针对儿科患者的未来研究，以实现对我们最年轻患者的最佳护理。
