Department of Anaesthesia, Queensland Children's Hospital, Brisbane, Queensland, Australia.
Paediatric Intensive Care Unit, Children's Hospital at Westmead, Sydney, New South Wales, Australia.
Emerg Med Australas. 2020 Apr;32(2):313-319. doi: 10.1111/1742-6723.13484. Epub 2020 Mar 9.
Haemorrhage in paediatric trauma remains a significant cause of morbidity and mortality. Over recent years there has been increasing attention to the role of fibrinogen in traumatic haemorrhage and the association of low fibrinogen levels with poor patient outcomes. In addition, there has been a move towards using viscoelastic haemostatic assays (VHAs) to rapidly assess coagulation status and guide clinicians in the replacement of coagulation factors, including fibrinogen. In the paediatric population, there has been limited uptake of these principles and a paucity of data to support a change in practice. This paper summarises the available evidence in the published literature through a systematic review, presented in narrative format.
There is limited high-quality prospective data on the use of VHA in the management of acute traumatic coagulopathy in the paediatric population. While the use of fibrinogen early in major haemorrhage is becoming standard practice, there are currently no randomised prospective studies comparing fibrinogen concentrate to cryoprecipitate.
The early identification of hypo-fibrinogenemia and acute traumatic coagulopathy in paediatric trauma using VHA testing and subsequent early fibrinogen replacement with a concentrated off the shelf product is an attractive treatment option. However, there is currently insufficient high-level evidence to support the use of fibrinogen concentrate over cryoprecipitate in the paediatric trauma population. Pilot studies currently under way will go some way to addressing this important knowledge gap, and facilitate the design of larger definitive multi-centre randomised trials.
小儿创伤性出血仍然是发病率和死亡率的重要原因。近年来，人们越来越关注纤维蛋白原在创伤性出血中的作用，以及低纤维蛋白原水平与患者预后不良的关系。此外，人们越来越倾向于使用粘弹性止血测定法（VHA）快速评估凝血状态，并指导临床医生替代凝血因子，包括纤维蛋白原。在儿科人群中，这些原则的应用有限，也缺乏支持实践改变的数据。本文通过系统评价，以叙述性格式总结了已发表文献中的现有证据。
在儿科人群中，急性创伤性凝血病管理中使用 VHA 的高质量前瞻性数据有限。虽然在大出血早期使用纤维蛋白原已成为标准做法，但目前尚无比较纤维蛋白原浓缩物与冷沉淀的随机前瞻性研究。
使用 VHA 检测早期识别小儿创伤性低纤维蛋白血症和急性创伤性凝血病，并随后使用现成的浓缩纤维蛋白原进行早期纤维蛋白原替代，是一种有吸引力的治疗选择。然而，目前尚无足够的高级别证据支持在儿科创伤人群中使用纤维蛋白原浓缩物替代冷沉淀。目前正在进行的试点研究将在一定程度上解决这一重要的知识空白，并有助于设计更大规模的、明确的多中心随机试验。
