Good afternoon, my name is Rob Russell and I'm a pediatric surgeon at UAB and Children's of Alabama. I really appreciate the opportunity to be a part of this session to highlight the important work that was performed by an excellent multidisciplinary group of colleagues in the interest of improving the outcomes for children and improving the quality of research in regard to plasma and platelet transfusions in pediatric patients. I have no disclosures. As Dr. Nellis has described in the opening presentation of the specifics of TAXICAB, the methodology and general guidelines, I will focus my remarks specifically to the plasma and platelet transfusion strategies and severe trauma and traumatic brain injury and non-traumatic intracranial hemorrhage. I do want to mention and give credit to the other members of our subgroup working on this specific topic. Marianne Nellis and Jacques Lacroix from Pediatric Critical Care Medicine, Thorsten Haas and Susan Gooby from Pediatric Anesthesia, Adam Vogel from Pediatric Surgery, David Bauer from Pediatric Neurosurgery and Daniel Nishijima from Pediatric Emergency Medicine. In addition to all the members of the TAXICAB initiative who participated in the meetings and voted in regard to these recommendations. To give you a brief overview of the literature review we did regarding plasma and platelet transfusions in pediatric trauma and traumatic brain injury patients. We started with 3,400 abstracts and that was whittled down to 105 articles that underwent full text review and 29 articles that we believe contained original data regarding this topic. In reference to the literature specific to plasma and platelet transfusions and pediatric traumatic brain injury and intracranial hemorrhage, we started with just over 2,200 articles, or excuse me, 2,200 abstracts that were screened down to 93 full text articles and one article that had specific information related to plasma and platelet transfusions and pediatric traumatic brain injury and intracranial hemorrhage. As you likely know, most, if not all of these studies for both topics may have evaluated a specific topic hypothesis, overall resuscitation strategy so it was always difficult to tease out the specifics related to plasma and platelets within the frame of the entire resuscitation strategy. The entire list of articles that were abstracted and evaluated for bias are available as a supplement to this article. With this amount of literature and all being mostly retrospective studies, we had to rely on expert opinion in regard to many of our recommendations and without overwhelming quality of data, these statements have to be worded carefully. As Dr. Nellis detailed, we put forth some good practice statements, which are those in which there's a high level of certainty that the practice is in the best interest of the patient, but there's little definitive specific supporting literature and also in these subsequent slides with the statements and recommendations, I've included the percentage agreement of the voters at the end. So for this subgroup, we had one good practice statement, which was in critically ill pediatric patients with severe trauma, traumatic brain injury and non-traumatic intracranial hemorrhage, we suggest close monitoring of bleeding, including the evaluation of potential expansion of intracranial hemorrhage and serial evaluation of the coagulation system. We do know that estimates of clinically significant coagulopathy in pediatric trauma patients, including those with traumatic brain injury are wide between 25 to 75 percent, depending on the mechanism, injury severity and specific subpopulations. These patients show some alterations in their coagulation system, whether it be platelets, PT, INR, fibrinogen. Although there is some ongoing debate about the exact physiology of trauma-induced coagulopathy and all of its contributors, we feel it is prudent to serially evaluate the coagulation system with standard coagulation tests, platelet counts and or fibrinogen, elastometry or elastography, especially while active resuscitation is going on. The frequency of that should be at the discretion of the provider and should be liberalized as the resuscitation nears end and values trend towards normal. In addition, we put forth several expert consensus statements that were put together by this group and vetted on by the full panel of experts and required 80 percent agreement. These were done in the absence of quality literature and areas where research is needed. Unfortunately, in these populations of pediatric patients with severe trauma, TBI and non-traumatic intracranial hemorrhage, there was insufficient evidence to make any recommendation regarding specific indications or transfusion strategies to direct plasma or platelet transfusions. However, that dovetails with our next recommendation that those patients in hemorrhagic shock following trauma, a resuscitation strategy of red blood cells, plasma and platelets and ratios between 1 to 1 to 1 to 2 to 1 to 1 might be considered. Massive transfusion can be delivered with components in a given ratio or with a transfusion of whole blood. There have been multiple studies looking at massive transfusion in children and civilian and combat injured patients. The outcomes of these studies are inconsistent and it is difficult to tease out the specific effects of plasma or platelets that are given in tandem toward a balanced resuscitation. Even in this lack of definitive evidence, the Tacticab experts concluded that a balanced resuscitation strategy or ratios in children with hemorrhagic shock or life-threatening bleeding might be considered. Here's a list of the most recent studies evaluating massive transfusion in children. As you can see on the left side of the screen, many find benefits of a balanced or high risk ratio of plasma and packed red blood cells. These benefits may be in decreased mortality, decreased products utilized and or decreased hospital length of stay or ventilator days. On the other side, there are others that have failed to show benefit with these balanced resuscitation strategies. Most of these studies are earlier studies, more in the combat population. We also looked at how we may monitor these patients prior to and during their resuscitation. And in this statement, we put forth that critically ill pediatric patients with severe trauma, TBI or non-traumatic intracranial hemorrhage, viscoelastic monitoring with whether it be thromboelastometry, TAG or Rotem might be considered as an adjunct to standard laboratory hemostatic testing to inform decisions regarding the transfusion of plasma or platelets. Two randomized control trials in adult trauma looking at utilization of TAG versus conventional coagulation tests for resuscitation. The iTactic trial showed no difference with viscoelastic assay augmented resuscitation protocols. However, the study from Denver Health showed decreased mortality in those adult patients resuscitated with TAG versus conventional coagulation tests. There's no specific pediatric literature to provide guidance on which coagulation system tests should be used or monitored with severe trauma, TBI or intracranial hemorrhage. Some centers do utilize TAG for resuscitation and as additional guiding information. Next, we tried to tackle platelet thresholds. So in a neurologically stable patient, pediatric patient with severe trauma, TBI or intracranial hemorrhage, platelet transfusion if the platelets are greater than 100,000 may not be beneficial. In situations with neurologic instability, reasons for neurologic deterioration should be evaluated to make sure that there's no expanding hematoma or intracranial hemorrhage related to coagulopathy. We could not reach a consensus on a threshold platelet count that could guide platelet transfusion. The ASA suggests a threshold of 50,000 in surgical patients in the presence of significant bleeding, but it is difficult to make a definitive recommendation in this setting without considering the clinical situation and other hematologic parameters. If an intracranial pressure monitor or monitoring device must be inserted in a neurologically deteriorating critically ill pediatric patient, platelet transfusion might be considered if the platelet count is less than 100,000. Again, this is a guiding recommendation based on expert opinion for consideration as there is no specific guiding literature in pediatric patients. The American Society of Neurosurgery nor ASA make recommendations on threshold platelet counts for monitor placement. The last expert recommendation, if an intracranial pressure monitoring device must be inserted in a neurologically deteriorating critically ill pediatric patient, if the INR is less than or equal to 1.5, plasma transfusion may not be beneficial. There are only small studies to suggest that bleeding risk in adult patients with placement of a ventriculostomy with an INR of less than or equal to 1.6 is very low. Other studies suggest that normal coagulation parameters are not needed prior to placement of intracranial pressure monitors and leads to a delay in placement. We cannot reach a consensus regarding management of INR over 1.5, but there is some evidence in critically ill pediatric populations that plasma transfusions significantly improved INR only in patients with a baseline INR of greater than 2.5. So in conclusion, unfortunately, there is little pediatric specific literature in this subpopulation to definitively support thresholds for coagulation test monitoring and for the transfusion of plasma and platelets. The good practice statements and expert consensus statements give a guiding framework on the best available literature and the extrapolation of adult studies. However, as I mentioned, the individual elements of the resuscitation of these patients is very hard to tease out in these studies. Certainly, research priorities in this specific population are critical to our groups as we consider resuscitation strategies as we move forward. Again, I appreciate the opportunity to present and look forward to answering any questions. Thank you.

pediatric patients

plasma transfusion

platelet transfusion

severe trauma

traumatic brain injury