Timing and Volume of Crystalloid and Blood Products in Pediatric Trauma – An EAST Multicenter Prospective Observational Study.

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The purpose of this study was to determine the relationship between timing and volume of crystalloid prior to blood products and mortality, hypothesizing that earlier transfusion and decreased crystalloid prior to transfusion would be associated with improved outcomes.A multi-institutional prospective observational study of pediatric trauma patients <18 years old, transported from the scene of injury with elevated age-adjusted shock index on arrival, was performed from 4/2018-9/2019. Volume and timing of prehospital, emergency department, and initial admission resuscitation were assessed including calculation of 20±10 mL/kg crystalloid boluses overall and prior to transfusion. Multivariable cox proportional hazards and logistic regression models identified factors associated with mortality and extended intensive care, ventilator, and hospital days.In 712 children at 24 trauma centers, mean age was 7.6 years, median (IQR) ISS 9 (2, 20), and in-hospital mortality 5.3% (n=38). There were 311 (43.7%) patients who received at least one crystalloid bolus and 149 (20.9%) who received blood including 65 (9.6%) with massive transfusion activation. Half (53.3%) of patients who received >1 crystalloid bolus required transfusion. Patients who received blood first (n=41) had shorter median time to transfusion (19.8 vs 78.0 minutes, p=.005) and less total fluid volume (50.4 vs 86.6 mL/kg, p=.033) than those who received crystalloid first despite similar ISS (median 22 vs 27, p=.40). On multivariable analysis there was no association with mortality (p=.51) however each crystalloid bolus after the first was incrementally associated with increased odds of extended ventilator, ICU, and hospital days (all p1 crystalloid bolus was associated with increased need for transfusion and worse outcomes including extended duration of mechanical ventilation and hospitalization in this prospective study. These data support a crystalloid-sparing, early transfusion approach for resuscitation of injured children.Level III, Therapeutic.

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