From the Division of Trauma and Burn Surgery (T.M.S., G.J.S., W.V.G.-T., R.S.B.), Children's National Hospital, Washington, DC; Department of Surgery (A.R.J.), University of California San Francisco; and Division of Pediatric Surgery (A.R.J.), UCSF Benioff Children's Hospitals, San Francisco, CA.
J Trauma Acute Care Surg. 2024 May 1;96(5):785-792. doi: 10.1097/TA.0000000000004119. Epub 2023 Sep 27.
Studies of hemorrhage following pediatric injury often use the occurrence of transfusion as a surrogate definition for the clinical need for a transfusion. Using this approach, patients who are bleeding but die before receiving a transfusion are misclassified as not needing a transfusion. In this study, we aimed to evaluate the potential for this survival bias and to estimate its presence among a retrospective observational cohort of children and adolescents who died from injury.
We obtained patient, injury, and resuscitation characteristics from the 2017 to 2020 Trauma Quality Improvement Program database of children and adolescents (younger than 18 years) who arrived with or without signs of life and died. We performed univariate analysis and a multivariable logistic regression to analyze the association between the time to death and the occurrence of transfusion within 4 hours after hospital arrival controlling for initial vital signs, injury type, body regions injured, and scene versus transfer status.
We included 6,063 children who died from either a blunt or penetrating injury. We observed that children who died within 15 minutes had lower odds of receiving a transfusion (odds ratio, 0.1; 95% confidence interval, 0.1-0.2) compared with those who survived longer. We estimated that survival bias that occurs when using transfusion administration alone to define hemorrhagic shock may occur in up to 11% of all children who died following a blunt or penetrating injury but less than 1% of all children managed as trauma activations.
Using the occurrence of transfusion alone may underestimate the number of children who die from uncontrolled hemorrhage early after injury. Additional variables than just transfusion administration are needed to more accurately identify the presence of hemorrhagic shock among injured children and adolescents.
Prognostic and Epidemiological; Level III.
儿科损伤后出血的研究通常使用输血的发生作为输血临床需求的替代定义。使用这种方法，在接受输血前出血但死亡的患者被错误地归类为不需要输血。在这项研究中，我们旨在评估这种生存偏差的可能性，并估计其在回顾性观察性儿童和青少年损伤死亡队列中的存在情况。
我们从 2017 年至 2020 年创伤质量改进计划数据库中获取了儿童和青少年（<18 岁）患者、损伤和复苏特征，这些患者到达时有无生命体征，死亡。我们进行了单变量分析和多变量逻辑回归分析，以分析死亡时间与输血之间的关系，在控制初始生命体征、损伤类型、受伤身体部位以及现场与转运状态后，输血在入院后 4 小时内发生。
我们纳入了 6063 名因钝器或穿透伤而死亡的儿童。我们观察到，在 15 分钟内死亡的儿童接受输血的可能性较低（比值比，0.1；95%置信区间，0.1-0.2），与存活时间较长的儿童相比。我们估计，当仅使用输血管理来定义出血性休克时，可能会发生高达 11%的所有钝器或穿透伤后死亡的儿童存在生存偏差，但在所有作为创伤激活管理的儿童中，这种情况不到 1%。
仅使用输血的发生可能会低估受伤后早期因无法控制的出血而死亡的儿童数量。需要除输血管理以外的其他变量来更准确地识别受伤儿童和青少年中出血性休克的存在情况。
预后和流行病学；III 级。
