Spinella Philip C, Leonard Julie C, Marshall Callie, Luther James F, Wisniewski Stephen R, Josephson Cassandra D, Leeper Christine M
Department of Surgery, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH.
Pediatr Crit Care Med. 2022 Apr 1;23(4):235-244. doi: 10.1097/PCC.0000000000002907. Epub 2022 Feb 28.
To assess the impact of plasma and platelet ratios and deficits in injured children with life-threatening bleeding.
Secondary analysis of the MAssive Transfusion epidemiology and outcomes In Children study dataset, a prospective observational study of children with life-threatening bleeding events.
Twenty-four childrens hospitals in the United States, Canada, and Italy.
Injured children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under activation of massive transfusion protocol.
INTERVENTION/EXPOSURE: Weight-adjusted blood product volumes received during the bleeding event were recorded. Plasma:RBC ratio (plasma/RBC weight-adjusted volume in mL/kg) and platelet:RBC ratio (platelet/RBC weight-adjusted volume in mL/kg) were analyzed. Plasma deficit was calculated as RBC mL/kg - plasma mL/kg; platelet deficit was calculated as RBC mL/kg - platelet mL/kg.
Of 191 patients analyzed, median (interquartile range) age was 10 years (5-15 yr), 61% were male, 61% blunt mechanism, and median (interquartile range) Injury Severity Score was 29 (24-38). After adjusting for Pediatric Risk of Mortality score, cardiac arrest, use of vasoactive medications, and blunt mechanism, a high plasma:RBC ratio (> 1:2) was associated with improved 6-hour survival compared with a low plasma:RBC ratio (odds ratio [95% CI] = 0.12 [0.03-0.52]; p = 0.004). Platelet:RBC ratio was not associated with survival. After adjusting for age, Pediatric Risk of Mortality score, cardiac arrest, and mechanism of injury, 6-hour and 24-hour mortality were increased in children with greater plasma deficits (10% and 20% increased odds of mortality for every 10 mL/kg plasma deficit at 6 hr [p = 0.04] and 24 hr [p = 0.01], respectively); 24-hour mortality was increased in children with greater platelet deficits (10% increased odds of 24-hr mortality for every 10 mL/kg platelet deficit [p = 0.02)]).
In injured children, balanced resuscitation may improve early survival according to this hypothesis generating study. Multicenter clinical trials are needed to assess whether clinicians should target ratios and deficits as optimal pediatric hemostatic resuscitation practice.
评估血浆与红细胞比例及血小板与红细胞比例对有危及生命出血的受伤儿童的影响。
对儿童大量输血流行病学与结局研究数据集进行二次分析，这是一项对有危及生命出血事件儿童的前瞻性观察性研究。
美国、加拿大和意大利的24家儿童医院。
0至17岁的受伤儿童，他们在6小时内接受的全血制品总量超过40 mL/kg，或在大量输血方案启动下接受输血。
干预/暴露：记录出血事件期间接受的体重调整后的血制品量。分析血浆与红细胞比例（血浆/红细胞体重调整后的体积，单位为mL/kg）和血小板与红细胞比例（血小板/红细胞体重调整后的体积，单位为mL/kg）。血浆亏缺计算为红细胞mL/kg减去血浆mL/kg；血小板亏缺计算为红细胞mL/kg减去血小板mL/kg。
在分析的191例患者中，中位（四分位间距）年龄为10岁（5至15岁），61%为男性，61%为钝性机制损伤，中位（四分位间距）损伤严重程度评分为29分（24至38分）。在调整了儿科死亡风险评分、心脏骤停、血管活性药物使用和钝性机制损伤后，与低血浆与红细胞比例相比，高血浆与红细胞比例（>1:2）与6小时生存率提高相关（优势比[95%置信区间]=0.12[0.03至0.52]；p=0.004）。血小板与红细胞比例与生存率无关。在调整了年龄、儿科死亡风险评分、心脏骤停和损伤机制后，血浆亏缺较大的儿童6小时和24小时死亡率升高（每10 mL/kg血浆亏缺在6小时和24小时时死亡率分别增加10%和20%[p=0.04和p=0.01]）；血小板亏缺较大的儿童24小时死亡率升高（每10 mL/kg血小板亏缺24小时死亡率增加10%[p=0.02]）。
在受伤儿童中，根据这项产生假设的研究，平衡复苏可能改善早期生存率。需要进行多中心临床试验来评估临床医生是否应将比例和亏缺作为最佳儿科止血复苏实践的目标。
