• Stephanie F Polites, Suzanne Moody, Regan F Williams, Mark L Kayton, Emily C Alberto, Randall S Burd, Thomas J Schroeppel, Joanne E Baerg, Amanda Munoz, William B Rothstein, Laura A Boomer, Eric M Campion, Caitlin Robinson, Rachel M Nygaard, Chad J Richardson, Denise I Garcia, Christian J Streck, Michaela Gaffley, John K Petty, Cynthia Greenwell, Samir Pandya, Alicia M Waters, Robert T Russell, Brian K Yorkgitis, Jennifer Mull, Jeffrey Pence, Matthew T Santore, Taleen MacArthur, Denise B Klinkner, Shawn D Safford, Tanya Trevilian, Adam M Vogel, Megan Cunningham, Christa Black, Jessica Rea, Ryan G Spurrier, Aaron R Jensen, Bethany J Farr, David P Mooney, Bavana Ketha, Melvin S Dassinger, Anna Goldenberg-Sandau, Roman Janika San JS, Todd M Jenkins, and Richard A Falcone.
• From the Division of Pediatric General and Thoracic Surgery (S.F.P., S.M., R.A.F., T.M.J.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Le Bonheur Children's Hospital (R.F.W.), Memphis, Tennessee; College of Medicine (M.L.K.), Florida Atlantic University, Boca Raton, Florida and the Palm Beach Children's Hospital, West Palm Beach, Florida; Children's National Medical Center (E.C.A., R.S.B.), Washington, DC; UCHealth Memorial Hospital (T.J.S.), Colorado Springs, Colorado; Loma Linda University (J.E.B., A.M.), Loma Linda, California; Children's Hospital of Richmond (W.B.R., L.A.B.), Virginia Commonwealth University, Richmond, Virginia; Denver Health Medical Center (E.M.C., C.R.), Denver, Colorado; Hennepin Healthcare (R.M.N., C.J.R.), Minneapolis, Minnesota; The Medical University of South Carolina (D.I.G., C.J.S.), Charleston, South Carolina; Wake Forest Baptist Medical Center (M.G., J.K.P.), Brenner Children's Hospital, Winston-Salem, North Carolina; Children's Health Dallas (C.G., S.P.), Dallas, Texas; Children's of Alabama (A.M.W., R.T.R.), Birmingham, Alabama; College of Medicine (B.K.Y., J.M.), University of Florida-Jacksonville, Jacksonville, Florida; Dayton Children's Hospital (J.P.), Dayton, OH; Children's Healthcare of Atlanta (M.T.S.), Atlanta, Georgia; Mayo Clinic (T.M., D.B.K.), Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota; Carilion Children's Hospital (S.D.S., T.T.), Carilion Roanoke Memorial Hospital, Roanoke, Virginia; Texas Children's Hospital (A.M.V., M.C.), Houston, Texas; ProMedica Toledo and Toledo Children's Hospital (C.B.), Toledo, Ohio; Children's Hospital Los Angeles (J.R., R.G.S., A.R.J.), Los Angeles, California; Boston Children's Hospital (B.J.F., D.P.M.), Boston, Massachusetts; Arkansas Children's Hospital (B.K., M.S.D.), Little Rock, Arkansas; and Cooper University Hospital (A.G.-S., J.S.R.), Camden, New Jersey.
• J Trauma Acute Care Surg. 2020 Jul 1; 89 (1): 36-42.

BackgroundThe purpose of this study was to determine the relationship between timing and volume of crystalloid before blood products and mortality, hypothesizing that earlier transfusion and decreased crystalloid before transfusion would be associated with improved outcomes.MethodsA multi-institutional prospective observational study of pediatric trauma patients younger than 18 years, transported from the scene of injury with elevated age-adjusted shock index on arrival, was performed from April 2018 to September 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 before transfusion. Multivariable Cox proportional hazards and logistic regression models identified factors associated with mortality and extended intensive care, ventilator, and hospital days.ResultsIn 712 children at 24 trauma centers, mean age was 7.6 years, median (interquartile range) Injury Severity Score was 9 (2-20), and in-hospital mortality was 5.3% (n = 38). There were 311 patients(43.7%) 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 greater than one crystalloid bolus required transfusion. Patients who received blood first (n = 41) had shorter median time to transfusion (19.8 vs. 78.0 minutes, p = 0.005) and less total fluid volume (50.4 vs. 86.6 mL/kg, p = 0.033) than those who received crystalloid first despite similar Injury Severity Score (median, 22 vs. 27, p = 0.40). On multivariable analysis, there was no association with mortality (p = 0.51); however, each crystalloid bolus after the first was incrementally associated with increased odds of extended ventilator, intensive care unit, and hospital days (all p < 0.05). Longer time to transfusion was associated with extended ventilator duration (odds ratio, 1.11; p = 0.04).ConclusionResuscitation with greater than one 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 Of EvidenceTherapeutic, level IV.

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