Survival Bias in Pediatric Hemorrhagic Shock: Are We Misrepresenting the Data?
Journal
The journal of trauma and acute care surgery
ISSN: 2163-0763
Titre abrégé: J Trauma Acute Care Surg
Pays: United States
ID NLM: 101570622
Informations de publication
Date de publication:
27 Sep 2023
27 Sep 2023
Historique:
pubmed:
27
9
2023
medline:
27
9
2023
entrez:
27
9
2023
Statut:
aheadofprint
Résumé
Studies of hemorrhage following pediatric injury often use the occurrence of transfusion as a surrogate definition for the clinical need for a transfusion. Using this approach, patients who are bleeding but die before receiving a transfusion are misclassified as not needing a transfusion. In this study, we aimed to evaluate the potential for this survival bias and to estimate its presence among a retrospective observational cohort of children and adolescents who died from injury. We obtained patient, injury, and resuscitation characteristics from the 2017 to 2020 Trauma Quality Improvement Program database of children and adolescents (age < 18 years) who arrived with or without signs of life and died. We performed univariate analysis and a multivariable logistic regression to analyze the association between the time to death and the occurrence of transfusion within four hours after hospital arrival controlling for initial vital signs, injury type, body regions injured, and scene versus transfer status. We included 6,063 children who died from either a blunt or penetrating injury. We observed that children who died within 15 minutes had lower odds of receiving a transfusion (odds ratio [OR] = 0.1, 95% CI = 0.1, 0.2) compared to those who survived longer. We estimated that survival bias that occurs when using transfusion administration alone to define hemorrhagic shock may occur in up to 11% of all children who died following a blunt or penetrating injury but less than 1% of all children managed as trauma activations. Using the occurrence of transfusion alone may underestimate the number of children who die from uncontrolled hemorrhage early after injury. Additional variables than just transfusion administration are needed to more accurately identify the presence of hemorrhagic shock among injured children and adolescents. Prognostic and Epidemiological, Level III.
Sections du résumé
BACKGROUND
BACKGROUND
Studies of hemorrhage following pediatric injury often use the occurrence of transfusion as a surrogate definition for the clinical need for a transfusion. Using this approach, patients who are bleeding but die before receiving a transfusion are misclassified as not needing a transfusion. In this study, we aimed to evaluate the potential for this survival bias and to estimate its presence among a retrospective observational cohort of children and adolescents who died from injury.
METHODS
METHODS
We obtained patient, injury, and resuscitation characteristics from the 2017 to 2020 Trauma Quality Improvement Program database of children and adolescents (age < 18 years) who arrived with or without signs of life and died. We performed univariate analysis and a multivariable logistic regression to analyze the association between the time to death and the occurrence of transfusion within four hours after hospital arrival controlling for initial vital signs, injury type, body regions injured, and scene versus transfer status.
RESULTS
RESULTS
We included 6,063 children who died from either a blunt or penetrating injury. We observed that children who died within 15 minutes had lower odds of receiving a transfusion (odds ratio [OR] = 0.1, 95% CI = 0.1, 0.2) compared to those who survived longer. We estimated that survival bias that occurs when using transfusion administration alone to define hemorrhagic shock may occur in up to 11% of all children who died following a blunt or penetrating injury but less than 1% of all children managed as trauma activations.
CONCLUSION
CONCLUSIONS
Using the occurrence of transfusion alone may underestimate the number of children who die from uncontrolled hemorrhage early after injury. Additional variables than just transfusion administration are needed to more accurately identify the presence of hemorrhagic shock among injured children and adolescents.
LEVEL OF EVIDENCE
METHODS
Prognostic and Epidemiological, Level III.
Identifiants
pubmed: 37752639
doi: 10.1097/TA.0000000000004119
pii: 01586154-990000000-00507
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Déclaration de conflit d'intérêts
Conflicts of Interest: Author Disclosure forms have been supplied and are provided as Supplemental Digital Content ( http://links.lww.com/TA/D210 ).