OA2-AM24-MN-07 - Evaluation of Coagulopathy in Pediatric Cohort Undergoing Massive Transfusion

Monday, October 21, 2024

8:15 AM - 9:15 AM

Location: 362

CE: Zero

Presenting Author(s)

NW

Nathan R. Wilken, MD (he/him/his)

Assistant Professor
Department of Pathology, Baylor College of Medicine Transfusion Medicine, Texas Children's Hospital
Houston, Texas, United States

Disclosure(s): No financial relationships to disclose

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Disclosure(s):

Nathan R. Wilken, MD: No financial relationships to disclose

Background/Case Studies: The mortality rates associated with massive transfusion in pediatric patients remain alarmingly high, particularly when trauma-induced coagulopathy complicates the clinical picture, leading to adverse outcomes. Fibrinogen plays a pivotal role in hemostasis, and recent studies have scrutinized its significance in massive transfusion protocols, sparking discussions on the efficacy of fibrinogen replacement therapy. Despite these advances, there is a noticeable scarcity of data regarding fibrinogen replacement in pediatric populations, especially in the context of massive transfusion activations for non-trauma-related conditions. Addressing this gap is crucial for optimizing patient outcomes and refining transfusion strategies in pediatric critical care. This study aims to determine if pediatric non-trauma patients requiring massive transfusion protocol present with similar coagulation abnormalities with particular focus on fibrinogen status.

Study

Design/Methods: Retrospective observational study on massive transfusion protocol (MTP) activation in children (ages 0-18 years) at a quaternary care pediatric hospital from January, 2018 to December, 2023. Fibrinogen, measured by Clauss method using STA-Max as well as transfusion volume and early mortality (defined as mortality within 24 hours of MTP activation) were evaluated. ROC analysis performed to identify fibrinogen cut off. Patients were grouped according to trauma status and fibrinogen cut off.

Results/Findings: The study cohort included 136 pediatric patients (51 females, 85 males) with mean age of 9±6 years and weight 35±25 kg. Overall, there were forty-eight trauma (TR) and 88 non-trauma (NTR) related MTP activations. The majority of TR activations were in the emergency department (ED, 54%) whereas the majority of NTR activations occurred in an intensive care unit (ICU, 57%). ROC analysis for 24 hours mortality determined a fibrinogen cut off of 105 mg/dL, sensitivity 91.5% and false positive rate of 10.5%. Hypofibrinogenemia (< 105 mg/dL) was observed in 21% of TR and 19% of NTR. Mortality within 24 hours of MTP activation was higher in patients with hypofibrinogenemia (TR 70%, p< 0.001, NTR 59%, p< 0.001) regardless of trauma status. Additionally, aPTT was prolonged (TR p=0.01, NTR p=0.049) and INR was higher in patients with hypofibrinogenemia in TR and NTR (p< 0.001). Hypofibrinogenemia was associated with higher plasma transfusion requirement in TR (p=0.02).

Conclusions: Hypofibrinogenemia in both pediatric trauma and non-trauma related massive transfusion activations is associated with worse coagulopathy and higher early mortality. Low fibrinogen levels during an MTP activation may potentially predict higher transfusion requirements.