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Invited Commentary
February 17, 2021

Early Cryoprecipitate Use—Time to Change Our Pediatric Massive Transfusion Protocol?

Author Affiliations
  • 1Division of Pediatric Surgery, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
JAMA Surg. 2021;156(5):460-461. doi:10.1001/jamasurg.2020.7266

Transfusion practices in hemorrhagic shock have evolved over the last decade or more. Our understanding has benefited from extensive military experience with massive transfusion protocols, balanced resuscitation ratios, use of whole blood, and tranexamic acid. The role of these strategies in pediatric trauma care, however, is less clear.

Fibrinogen, a key component of cryoprecipitate, is one of the first factors to become depleted during trauma-induced coagulopathy. Previous work has shown that reduced initial fibrinogen levels are an independent predictor of in-hospital mortality.1 It stands to reason that early replacement would have salutary benefits. Recently, Ditillo et al2 reviewed Trauma Quality Improvement Program data and concluded that use of cryoprecipitate in massively transfused adult patients was associated with lower rates of 24-hour and in-hospital mortality. Now, in this issue of JAMA Surgery, Tama et al3 reviewed Pediatric Trauma Quality Improvement Program data and evaluated whether massively transfused children, those receiving greater than 40 mL/kg of blood product in the first 4 hours of arrival to the emergency department, benefited from early administration of cryoprecipitate.3 A propensity score was created to analyze a cohort of 1948 patients, of which 541 (27.8%) received cryoprecipitate within 4 hours. Patients who received cryoprecipitate had significantly lower 24-hour mortality (absolute risk difference, −6.9%). In addition, the authors noted a reduced 7-day mortality in children with penetrating trauma and those with transfusion in excess of 100 mL/kg.3

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