Article 1
Whole blood: total blood product ratio impacts survival in injured children. Feeney E, Morgan KM, Spinella PC, Gaines BA, Leeper CM. J Trauma Acute Care Surg. 2024 Apr 30.
The use of low-titer group O whole blood (LTOWB) has been associated with improved survival and decreased blood product usage in multiple recent observational studies primarily involving adult trauma patients. As such, the interest in and use of LTOWB in pediatric trauma is increasing. There is also recognition that a child’s response to hemorrhage may be physiologically different than an adult, calling into question whether LTOWB resuscitation in this population will have similar benefits. This is particularly relevant given that trauma is the leading cause of death in children and adolescents. As the authors discuss, most prior work has evaluated the use of LTOWB in addition to balanced component therapy, while less is known about the whole blood: total transfusion volume ratio (WB:TTV), essentially the “dose” of whole blood administered. The authors hypothesized that, in children who received LTOWB following injury, the proportion of LTOWB relative to the total blood product resuscitation volume would impact survival.
This single-center, retrospective cohort study evaluated 95 injured children (age < 18 years, median age 10 years, 58% male, 25% penetrating injuries, median ISS 26, 45% severe TBI, overall in-hospital mortality 34%) who received any amount of LTOWB in the first 4 hours after injury, with primary outcome of in-hospital mortality and multiple secondary outcomes of interest. A Youden index was used to a identify a WB:TTV threshold associated with improved survival. The authors found a 38% decrease in in-hospital mortality for each 10% increase in the proportion of WB relative to total transfusion volume when adjusting for pre-specified demographic and injury specific characteristics. A WB:TTV greater than 40% was the cutoff significantly associated with lower adjusted odds of in-hospital mortality. Similar results were found in the severe TBI sub-group, although this was a small sample size and overall this group received less balanced resuscitation. Within the noted limitations of the study, including retrospective design, relatively small single-center sample size, and unclear timing of LTOWB administration relative to component therapy resuscitation, these results suggest that LTOWB should be used as a first line resuscitative fluid in injured children when available.
Article 2
The use and timing of angioembolization in pediatric blunt liver and spleen injury. Naiditch JA, Notrica DM, Sayrs LW, Linnaus M, Stottlemyre R, Garcia NM, Lawson KA, Cohen AS, Letton RW, Johnson J, Maxson RT, Eubanks JW 3rd, Ryan M, Alder A, Ponsky TA, St Peter SD, Bhatia AM, Leys CM. J Trauma Acute Care Surg. 2024 Jun 1;96(6):915-920.
While angioembolization of solid organ injuries is prevalent in the adult population it is used and studied much less in the pediatric trauma population. In fact, cited studies showed that angioembolization (AE) was used in only 3-4% of pediatric blunt trauma patients. The aim of this study was to add to the paucity of literature investigating pediatric solid organ AE. This was a planned secondary analysis of a previous study evaluating pediatric blunt spleen and liver injury (BLSI) with the goal of describing how angiography and embolization is used in pediatric BLSI.
The study was conducted at 10 Level 1 pediatric trauma centers in the United States form 2013-2016 with inclusion criteria of patients <18 years of age who had a documented spleen or liver injury on CT scan. The study centers followed a specific algorithm for the nonoperative management of blunt solid organ injury that allowed for angioembolization (AE) when deemed appropriate by the treating physicians. This secondary analysis included all patients who underwent angiography with or without embolization. Primary outcomes were mortality and failure of nonoperative management (NOM). Secondary outcomes were complications and time to angiography/AE.
There were 1004 patients with BLSI in the study period. 30 (3.1%) underwent angiography and only 17 (1.7%) underwent AE. Patients undergoing angiography had spleen (36.7%), liver (33.3%) or combination spleen/liver injuries (30%). The vast majority of these were done in grade VI or V injuries though a small number were lower grade. Of all angiography patients, 33.3% failed NOM, whereas only 23.5% of AE patients did. Of note, no patients who underwent splenic AE required splenectomy whereas 2 patients in angiography group did require splenectomy. Angioembolization of the liver was less successful in avoiding operations with 50% of these patients (n=4) undergoing operative intervention- 2 for bleeding control and 2 for drain placement.
The study concludes that AE can be an important tool in pediatric BLSI. This seems a reasonable conclusion given no splenectomies were needed in those children undergoing AE; however, the numbers are quite small limiting the ability to make firm conclusions. Hepatic AE seemed to be less effective in avoiding operations but again the conclusions are limited by the small study size. Interestingly, median time from arrival at the trauma center to angiography was 6.43 hours in these patients which the authors argue should allow for relaxation of the ACS guidelines for IR availability within 60 minutes. I feel this is a hard conclusion to draw from these data. While the patients in this study appeared to do okay with a prolonged time to IR it is easily imaginable that emergent IR availability would still be necessary in some cases and the question could be raised in the NOM failure cases whether time to AE played a factor.
Overall, the paper makes a valuable contribution to a subject which has little literature and provides support to the idea that angiography and AE can be valuable in pediatric patients. It is encumbered by the small sample size and also that the data is 8 years old. This would support that further research should be done to identify the proper patients in which AE should be used.
