title: The effects of balanced blood component resuscitation and crystalloid administration in pediatric trauma patients requiring transfusion in Afghanistan and Iraq 2002 to 2012.
abstract: BACKGROUND
  Component balanced resuscitation and avoidance of crystalloids in traumatically injured adults requiring massive transfusion are beneficial. Evidence for children is lacking.
  
  
  METHODS
  After institutional review board approval was obtained, the Department of Defense Trauma Database identified 1,311 injured children 14 years or younger requiring transfusion after an injury and admitted to a deployed US military hospital from 2002 to 2012. Logistic regression determined risk factors for high-volume (≥40 mL/kg) or massive (≥70 mL/kg) transfusions. The effects of crystalloid and balanced component resuscitation in the first 24 hours were assessed.
  
  
  RESULTS
  Nine hundred seven patients had recorded data sufficient for analysis. Two hundred twenty-four children received high-volume transfusion, and 77 received massive transfusions. Mortality was significantly higher for massive transfusions and high-volume transfusions than others (25% vs. 10% and 19% vs. 9%, respectively). Age of less than 4 years, penetrating injury, and Injury Severity Score (ISS) greater than 15 were associated with high-volume transfusions; an ISS greater than 15 and penetrating injury were associated with massive transfusions. Increased crystalloid administration showed a significant positive association with hospital days and intensive care unit days for both massive and high-volume transfusions, as well as a significant positive association with increased ventilator days in patients with high-volume transfusions. Balanced component resuscitation was not associated with improved measured outcomes and was independently associated with a higher mortality when all transfused patients were considered.
  
  
  CONCLUSIONS
  In this cohort, heavy reliance on crystalloid for resuscitation had an adverse effect on outcomes. Balanced component resuscitation did not improve outcomes and was associated with higher mortality when all transfused patients were considered. Further study is needed regarding efficacy and clinical triggers for the implementation of massive transfusion in children.
  
  
  METHODS
  Prognostic study, level IV.
authors.affiliation: From the Department of Surgery (M.J.E.), San Antonio Military Medical Center, San Antonio; and Department of Trauma (D.T.), UT Southwestern, Dell Children's Medical Center, Austin, Texas; Department of Clinical Investigation (M.B.L.) and Department of Surgery (M.E.C.), Tripler Army Medical Center, Honolulu, Hawaii; Hospitalist Division (K.M.C.), Children's National Medical Center, Washington, District of Columbia.
authors.forename: Mary J
authors.initials: MJ
authors.lastname: Edwards
authors.forename: Michael B
authors.initials: MB
authors.lastname: Lustik
authors.forename: Margaret E
authors.initials: ME
authors.lastname: Clark
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Creamer
authors.forename: David
authors.initials: D
authors.lastname: Tuggle
mesh_terms: D000293:Adolescent; D000346:Afghanistan / Q000453:epidemiology; D016913:Blood Component Transfusion / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D003422:Critical Care / Q000706:statistics & numerical data; D000077324:Crystalloid Solutions; D005260:Female; D017052:Hospital Mortality; D006772:Hospitals, Military; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007493:Iraq / Q000453:epidemiology; D007552:Isotonic Solutions / Q000627:therapeutic use*; D007902:Length of Stay / Q000706:statistics & numerical data; D012121:Respiration, Artificial / Q000706:statistics & numerical data; D012151:Resuscitation / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy*
chemical_list: D000077324:Crystalloid Solutions; D007552:Isotonic Solutions