Does Crystalloid Harm Pediatric Hemorrhagic Shock Patients?

Written by Michael Wolf

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Resuscitating pediatric trauma patients in hemorrhagic shock with >1 crystalloid bolus is associated with longer mechanical ventilation and ICU and hospital length of stay.

Why does this matter?
Children with hemorrhagic shock due to trauma have a high risk of in-hospital mortality. ATLS guidelines acknowledge a move toward crystalloid restriction, but have so far been unable to make firm recommendations in the pediatric population due to limited evidence. 

There will be blood.
This multi-center prospective observational study enrolled pediatric trauma patients presenting to level I pediatric trauma centers with elevated age-adjusted shock index (SIPA) indicative of hemorrhagic shock. 1471 patients from 24 centers were enrolled. Overall hospital mortality was 5.3%. 311 patients (43.7%) received at least one crystalloid bolus; 146 (20.5%) received blood, and 65 (9.6%) had massive transfusion activation. Over half (53.3%) of patients who got more than one crystalloid bolus went on to get a transfusion. The 41 patients who received blood before any crystalloid had less total fluid volume administered, despite similar injury severity score (ISS) to those who received crystalloid first. Not surprisingly, their time to transfusion was almost 4 times shorter (19.8 vs. 78 minutes).

Who got transfused? Older patients, those with penetrating injury, higher ISS, and higher severity head, abdomen, or lower extremity trauma. How much? Median volume was 33.2 mL/kg red cells. Transfused patients did have higher mortality (22.8% vs. 0.7%), perhaps owing in large part to their higher injury severity.

Each crystalloid bolus received prior to transfer increased the odds of requiring extended ventilator days, ICU days, and hospital days.

Taken together, these findings confirm what many of us suspected all along: the preferred treatment for hemorrhagic shock is blood, not crystalloid. While interventional studies are needed to confirm this, it is reasonable to consider immediate transfusion for hemodynamically unstable pediatric trauma patients, or to transfuse after nonresponse to a single crystalloid bolus.

Source
Timing and Volume of Crystalloid and Blood Products in Pediatric Trauma – An EAST Multicenter Prospective Observational Study. J Trauma Acute Care Surg. 2020 Mar 30. doi: 10.1097/TA.0000000000002702. [Epub ahead of print]

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