July 12, 2019
Administering blood and blood products to children who've experienced traumatic injury is changing. A new optimal resuscitation scheme is on the horizon. In the updated 10th edition of the American College of Surgeons' Advanced Trauma Life Support (ATLS) program training, trauma professionals will switch to giving blood to pediatric patients earlier. Use of whole blood is also forthcoming for children.
Resuscitation changes and rationale
The new ATLS training shifts from giving 2 boluses of 20 cubic centimeters/kg (cc/kg) of crystalloid, such as normal saline or Ringer's lactate, to giving 1 bolus of 20 cc/kg. If the patient still needs more fluid as evidenced by ongoing hemorrhage or hemodynamic instability, the trauma professional would then switch to administering blood products, which would be given at 10 cc/kg.
"The hope would be that we would give children what they need earlier in the process," says Denise B. Klinkner, M.D., M.Ed., a pediatric surgeon and pediatric trauma medical director at Mayo Clinic's Level 1 Pediatric Trauma Center in Rochester, Minnesota, and chair of the Minnesota Committee on Trauma. "Instead of giving them 2 boluses of crystalloid, we'd give them blood. It's clear that with large amounts of bleeding, it's OK to give blood right away to children."
According to a study by Christopher Moir, M.D., a pediatric surgeon at Mayo Clinic's campus in Minnesota, and colleagues — published in the July 2018 issue of the Journal of Trauma Acute Care Surgery — children who received a second bolus of crystalloid often proceeded to need blood, providing supporting evidence for the current change of moving to administering blood earlier in resuscitation.
Dr. Klinkner explains that the concern with the previous resuscitation scheme was giving pediatric patients, whose blood volume is typically around 80 cc/kg, about half of their total blood volume in crystalloid, which does not give them oxygen-carrying capacity. This practice was prompting more edema in the following days, as fluid tends to travel out of the intravascular space into the rest of the body, potentially affecting ventilation, since children are more likely to develop pulmonary contusions.
The other problem with the past resuscitation scheme was that the lungs, while trying to heal, would get extra volume, which the lungs can't tolerate and leads to longer intubation. Crystalloid also increases intra-abdominal pressure, which puts pressure on the kidneys and the lungs, and makes ventilating the patient more difficult.
How the changes affect trauma centers in southern Minnesota
Dr. Klinkner says the shifts in ATLS training for pediatric resuscitation have several applications for trauma centers in the region, such as:
Quicker transfer
If a second bolus is administered to a trauma patient in your center, be aware that the patient will need more-rapid transfer to a higher level of care.
Blood availability
Level IV trauma centers are required to have blood available, per the Minnesota Department of Health criteria approved in December 2018. The new ATLS resuscitation scheme should prompt low-volume trauma centers to provide blood to injured children as they would for adult patients.
Reeducation
All trauma center personnel will need to learn about the new pediatric blood and blood product protocols. Nursing staff education will need revisiting, especially related to drawing up and having blood available in a per kilogram basis.
Moving toward whole blood administration
Though not widespread currently, Dr. Klinkner also points to a movement afoot to use whole blood for injured children, as opposed to separated components. Two U.S. sites that have been leaders in use of whole blood, including in affiliated level IV trauma centers and in helicopters prior to the patient's arrival at definitive care, are the University of Pittsburgh and the University of Texas at San Antonio. In San Antonio, whole blood is used for children as young as age 5 in the field or at the hospital, and it's used in the hospital at the University of Pittsburgh starting at age 2.
At Mayo Clinic, whole blood is available, and as of May 2019, it has been administered to one pediatric patient. Discussions are underway, and an official policy is pending. The intention is to use whole blood in all patients — pediatric and adult — in the near future.
Dr. Klinkner considers herself an advocate for whole blood use, as outcomes so far are encouraging and point to decreased mortality. For example, a study published in the April 2019 issue of Transfusion, indicates improved survival with whole blood use at the injury site compared with the previous treatment of crystalloid solutions or blood components.
She also supports use of whole blood specifically in children, as it requires use of fewer other blood products and thus less exposure to multiple blood donors than with components, and it can shorten hospitalizations.
For more information
Advanced Trauma Life Support. American College of Surgeons.
Polites SF, et al. Multicenter study of crystalloid boluses and transfusion in pediatric trauma — When to go to blood? Journal of Trauma and Acute Care Surgery. 2018;85:108.
Zhu CS, et al. Give the trauma patient what they bleed, when and where they need it: Establishing a comprehensive regional system of resuscitation based on patient need utilizing cold-stored, low-titer O+ whole blood. Transfusion. 2019;59:1429.