Hendrickson 2012
Methods Study design : Controlled before after study Duration: December 2008 – 15 months either side Follow up : Duration of hospital admission Participants Country : US
Setting : Paediatric level 2 trauma centre
Inclusion criteria : Pre MTP - ‘Trauma stat’ patients who received blood within 24 hours. MTP – ‘Trauma stat’ patients who received blood.
Number: 49 Pre MTP ; 53 MTP Mean age : 6.3 Pre MTP ; 6.1 MTP Sex : 17/49 F Pre MTP ; 16/53 MTP ISS : 22 Pre MTP ; 22 MTP
Other Rx : Average 13 ml/kg crystalloid Pre MTP ; 16 ml/kg MTP InterventionsPre MTP : Blood products at physician discretion (not described)
MTP : MTP designed for 5 different weight ranges
Outcomes Primary outcome Mortality :Pre MTP 23% (11/49) ; MTP 38% (20/53) Ventilator days : Pre MTP 6 days ; MTP 2 days
ICU days : Pre MTP 9 days ; MTP 7 days
Notes Small study. Shorter time to transfuse with higher FFP:PRBC ratio in MTP group. Only 50% had 70ml/kg and therefore massive
transfusion. Most deaths from head injury. Missing data fields.
Risk of bias
Random sequence generation Author’s judgement Support
(Selection bias) High risk Unrandomised
Allocation concealment High risk No concealment
Blinding of participants High risk Unblinded
Blinding of outcome High risk Unblinded
Incomplete outcome data Low risk All patients accounted for
Others None
Quality of the evidence (GRADE) very low
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Chidester
Methods Study design : Prospective chart review Duration : 1st Jan 2009 to 1st Jan 2011 Follow up : Hospital discharge Participants Country : US
Setting : Paediatric level 1 trauma centre
Inclusion criteria : Patients requiring blood transfusion. Trauma or surgical.
Number: 55 (22 MTP ; 33 non MTP)
Mean age : 9.6 years (both groups) – explicit data not included Sex : 78% Male (both groups) – explicit data not included ISS : 42 MTP ; 25 non MTP
Other Rx : Factor VIIa at physician discretion
InterventionsProspective chart review of patients given uncrossmatched blood either via an MTP or at physician discretion.
Outcomes Primary outcome Mortality : No significant difference in mortality (46%) between all groups.
Notes Small study. Underpowered. Very high mortality. Thromboembolic complications higher in non MTP group. Coagulopathy predictive of MTP activation. FVIIa no effect on mortality and correlated with higher product use. Used t-test on thromboembolic complications – not normal data.
Risk of bias
Random sequence generation Author Support
(Selection bias) High risk MTP discretionary
Allocation concealment High risk As above
Blinding of participants N/A
Blinding of outcome High risk Unblinded
Incomplete outcome data Medium 1 lost to follow up Others None
Quality of the evidence (GRADE) very low
2
Edwards
Methods Study design : Retrospective analysis of trauma registry database Duration : 2002-2012
Follow up : Not indicated Participants Country : Iraq and Afghanistan
Setting : US military hospitals in Iraq and Afghanistan
Inclusion criteria : Injured children (<14 yrs) requiring transfusion Number: 224 high volume (>40ml/kg); 77 massive transfusion (>70ml/kg)
Mean age : Not documented
Sex : 70% Male (high volume) ; 71% Male (massive transfusion) ISS : Higher ISS for massive transfusions
Other Rx : Looked at effect of crystalloid use
InterventionsRetrospectively examined effects of crystalloid and blood component resuscitation in first 24 hours
Outcomes Primary outcome Mortality : 18% crystalloid >150ml/kg ; 10% < 150 ml/kg. Non significant trend towards increased mortality with higher FFP/PRBC ratios.
Secondary outcome: ICU stay, ventilator days ;Increased crystalloid administration associated with increased LOS and ventilator days.
Notes Larger study. Good discussion of massive transfusion definitions.
Risk of bias
Random sequence generation Author Support
(Selection bias) High risk Acknowledged in paper
Allocation concealment High risk Unblinded
Blinding of participants N/A
Blinding of outcome High risk Unblinded
Incomplete outcome data High risk Multiple lost due to transfer Others None
Quality of the evidence (GRADE) very low
3
Nosanov
Methods Study design : Retrospective analysis using logistic regression Duration: January 1 2003 to December 31 2010
Follow up : N/A (retrospective) Participants Country : US
Setting : Level 1 Trauma Centre
Inclusion criteria : Age < 18. Trauma requiring transfusion > 50%
total blood volume.
Number: 105 Mean age : 12.4 Sex : 23 (25%) ISS : 25.8 Other Rx : nil
InterventionsRetrospective review comparing blood product ratios to outcomes.
Based on low, medium and high ratios of both plasma and platelets to PRBC.
Outcomes Primary outcome Mortality : No significant difference in mortality (18%) between all groups.
Notes Small study. Underpowered. Very complex with multiple subgroups analysed. Deaths within 24 hours excluded to mitigate survivor bias (when haemorrhagic deaths presumably occur).
Risk of bias
Random sequence generation Author Support
(Selection bias) High risk Retrospective
Allocation concealment High risk No concealment
Blinding of participants High risk Retrospective
Blinding of outcome High risk Unblinded
Incomplete outcome data Low risk All patients accounted for Others None
Quality of the evidence (GRADE) very low
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