High-Risk, Low-Volume: When Low Volume is the Critical Safety Event
Justin L. Lockman, MD MSEd, Myron Yaster MD, James Fehr MD
Today’s PAAD is our first from the journal Critical Care Medicine. As promised, we are expanding the list of journals we review and our reviewers. Justin and Jim continue the vital tradition of the pediatric anesthesiologist/intensivist (see: Yaster M, Davis PJ, Greeley WJ. The American Pediatric Critical Care Anesthesiologist: An Endangered Species Worth Saving. Anesth Analg. 2019 Feb;128(2):204-206. PMID: 30649042) and are our primary critical care medicine PAAD reviewers. You will be seeing more of their PAADs in the months ahead. Myron Yaster MD
Original article
Leonard JC, Josephson CD, Luther JF et al. Life-Threatening Bleeding in Children: A Prospective Observational Study. Critical Care Medicine. 2021 Nov; 49(11): 1943-54. PMID: 33990098
In the patient safety arena, “High-Risk, Low-Volume” therapies are the things that keep most of us up at night. Think: prone high-frequency ventilation, ECMO during CPR (e-CPR), or hemodialysis in a newborn. We can’t speak for everyone, but we don’t usually include damage control resuscitation (DCR)(1) for bleeding in trauma or surgical patients to be in this category… After all, that’s our bread and butter! That’s why we were so surprised to read this recent article by Leonard and colleagues in Critical Care Medicine. It turns out we were wrong on both counts.
Principles of DCR include “permissive hypotension; rapid surgical control; avoidance of hemodilution, acidosis, hypocalcemia, and hypothermia; and early empiric, balanced transfusion with RBCs, plasma, and platelets, or whole blood when available. Medical centers use massive transfusion protocols (MTPs) to standardize the resuscitation of patients with life-threatening bleeding using DCR principles”.(2) Nevertheless, there is wide variation amongst institutions in their MPT activation and blood product protocols, for example, who and what triggers activation, what is the ratio of plasma to red blood cells, use of anti-fibrinolytics, etc.(2)
In today’s PAAD, the authors utilized a multi-institutional collaborative network of 24 tertiary care children’s hospitals to identify children 0-17 years old who received massive transfusion (defined as more than 40 mL/kg of blood products within 6 hours) or had activation of an MTP. Importantly, more than 80% of MTP activations occurred in emergency departments (67%) or PICU (15%); only 17% in the OR. Hospital blood bank documentation was used for subject identification, so some intraoperative transfusions were likely not included. Nonetheless, across up to 5 years (centers had different start dates) at 24 centers, they only identified 449 children via these criteria. That’s just a handful per year per center, which definitely counts as a low volume, high risk therapy.
Moreover, some of their findings were really surprising to us. Here’s what was expected: trauma (46%) was more common than operative (34%) or medical (20%) causes of life-threatening bleeding. Sixty-one percent of children had hypotension and one quarter were hypothermic before the “event” (transfusion). And trauma was more common in older children (median age 10.4 years) while operative hemorrhage was more common in younger children (median age 2.1 years).
What shocked/surprised us:
- Operative mortality within 6 hours was 100% caused by hemorrhage
- Operative mortality within 24 hours was 94% caused by hemorrhage (while only 56% due to hemorrhage in the trauma cohort)
- Many children did not ever receive plasma (20%) or platelet (34%) therapy
- Those who did receive these therapies experienced important delays (median time for plasma and platelet initiation 34 and 42 minutes, respectively)
- Only 41% of patients received packed RBC transfusion before MTP was initiated
- 12.5% of patients received recombinant factor VIIa
We know that time is of the essence in these situations; adult data indicate a 5% increase in mortality for every minute of delay in transfusion.(3) We also know that balanced transfusion strategies improve survival in injured children without CNS injury.(4) And we know that, as the authors point out, “age-related maturation of the hemostatic system” has not been well studied but young children “less than 1 year old are particularly vulnerable.” We do not yet know whether factor VIIa is of benefit in children with trauma, but studies are ongoing.
Note that all centers in this study are tertiary children’s hospitals. So, it’s possible that practices may be different at other centers. Also, as the authors point out, there are systems-based obstacles to administering plasma and platelets early (and other supposed best practices). And we don’t really even know what all of the best practices are. Still, it seems that we are not as outstanding at resuscitating bleeding children as we thought, and that these events are far more rare than we imagined.
One final note: Thank goodness the authors have formed a collaborative to try to study these kinds of things. Some members of the Society for Pediatric Anesthesia have already formed similar collaboratives for high-risk, low-volume therapies (for example, the Pediatric Craniofacial Collaborative Group). But there is a great need for more national and international collaborations of this kind so that in the future we may actually be able to identify best practices and build systems to support these practices. If you have an idea for a collaborative, SPA makes it easy to connect with others who can help. Let’s get to work!
Justin L. Lockman, MD MSEd, Myron Yaster MD, James Fehr MD
References
1. Holcomb JB, Jenkins D, Rhee P, Johannigman J, Mahoney P, Mehta S, Cox ED, Gehrke MJ, Beilman GJ, Schreiber M, Flaherty SF, Grathwohl KW, Spinella PC, Perkins JG, Beekley AC, McMullin NR, Park MS, Gonzalez EA, Wade CE, Dubick MA, Schwab CW, Moore FA, Champion HR, Hoyt DB, Hess JR. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 2007;62:307-10.
2. Horst J, Leonard JC, Vogel A, Jacobs R, Spinella PC. A survey of US and Canadian hospitals' paediatric massive transfusion protocol policies. Transfus Med 2016;26:49-56.
3. Meyer DE, Vincent LE, Fox EE, OʼKeeffe T, Inaba K, Bulger E, Holcomb JB, Cotton BA. Every minute counts: Time to delivery of initial massive transfusion cooler and its impact on mortality. J Trauma Acute Care Surg 2017;83:19-24.
4. Hwu RS, Spinella PC, Keller MS, Baker D, Wallendorf M, Leonard JC. The effect of massive transfusion protocol implementation on pediatric trauma care. Transfusion 2016;56:2712-9.