Kids grow up so fast: national patterns of positive drug/alcohol screens among pediatric trauma patients.

BACKGROUND: National guidelines recommend screening all trauma patients for drug and alcohol use beginning at age 12, but no national data have examined rates of screening or positive results in this population. METHODS: We examined national testing rates and results among all trauma patients under 21 years old in the 2017 American College of Surgeons Trauma Quality Programs (TQP) database. RESULTS: Of a cohort of n = 157,450 pediatric and adolescent trauma patients, n = 45,443 (28.9%) were screened, and n = 16,662 (36.7%) of those had a positive result. While both testing and positive results increased with age, testing rates were only 61.7% by age 20 and the prevalence of positive results was significant even at younger ages. Cannabinoids were the most commonly detected substance, followed by alcohol, and then opioids. CONCLUSIONS: These national data support the need for further efforts to increase screening rates and provide structured interventions to mitigate the consequences of substance abuse. IMPACT: These data provide the first national evidence of underutilization of drug and alcohol screening in pediatric and adolescent trauma patients, with substantial rates of positive screens among those tested. Cannabinoids were the most commonly detected substance, followed by alcohol and then opioids. These data should guide physicians' and policymakers' efforts to improve screening in this high-risk population, which will amplify the potential benefits of using the trauma admission as a critical opportunity to intervene with structured programs to mitigate the consequences of substance abuse.

Increased resource use in lung transplant admissions in the lung allocation score era.

RATIONALE: In 2005, the lung allocation score (LAS) was implemented to prioritize organ allocation to minimize waiting-list mortality and maximize 1-year survival. It resulted in transplantation of older and sicker patients without changing 1-year survival. Its effect on resource use is unknown. OBJECTIVES: To determine changes in resource use over time in lung transplant admissions. METHODS: Solid organ transplant recipients were identified within the Nationwide Inpatient Sample (NIS) data from 2000 to 2011. Joinpoint regression methodology was performed to identify a time point of change in mean total hospital charges among lung transplant and other solid-organ transplant recipients. Two temporal lung transplant recipient cohorts identified by joinpoint regression were compared for baseline characteristics and resource use, including total charges for index hospitalization, charges per day, length of stay, discharge disposition, tracheostomy, and need for extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS: A significant point of increased total hospital charges occurred for lung transplant recipients in 2005, corresponding to LAS implementation, which was not seen in other solid-organ transplant recipients. Total transplant hospital charges increased by 40% in the post-LAS cohort ($569,942 [$53,229] vs. $407,489 [$28,360]) along with an increased median length of stay, daily charges, and discharge disposition other than to home. Post-LAS recipients also had higher post-transplant use of extracorporeal membrane oxygenation (odds ratio, 2.35; 95% confidence interval, 1.56-3.55) and higher incidence of tracheostomy (odds ratio, 1.52; 95% confidence interval, 1.22-1.89). CONCLUSIONS: LAS implementation is associated with a significant increase in resource use during index hospitalization for lung transplant.

Complications of catheter-based electrophysiology procedures in adults with congenital heart disease: a national analysis.

OBJECTIVE: To determine whether adult congenital heart disease patients (ACHD) undergoing catheter-based electrophysiology (EP) procedures have an increased risk for complications compared with adults without congenital heart disease. DESIGN: Retrospective cohort study of a national administrative database. SETTING: Nationwide Inpatient Sample, 1998 through 2011. PARTICIPANTS: All admission records of patients who underwent a catheter-based electrophysiology procedure, categorized based on the presence or absence of ACHD. INTERVENTIONS: ACHD and non-ACHD cohorts were compared with respect to baseline, procedural, and outcome characteristics. MEASUREMENTS AND MAIN RESULTS: ACHD patients accounted for n=15,133 (1.7%) of n=873,437 EP procedure admissions and comprised a significantly increasing proportion over the study period (from 0.8% in 1998 to 2.4% in 2011, p<0.0001). ACHD patients were younger than non-ACHD patients (52.5±0.3 years v 61.9±0.04 years; p<0.0001), had a longer length of stay (4.6±0.1 days v 4.4±0.01 days, p=0.013), higher total hospital charges ($89,485±$1,543 v $70,456±$175, p<0.0001), and a higher rate of procedure-related complications (odds ratio 1.66, 95% confidence interval 1.49-1.85, p<0.0001). On multivariate analysis, ACHD patients continued to demonstrate an increased risk of procedural complications (odds ratio 1.95, 95% confidence interval 1.75-2.19, p<0.0001). CONCLUSIONS: ACHD patients experienced greater morbidity after catheter-based EP procedures. This finding will be of increasing significance as ACHD patients occupy a growing segment of the population undergoing these procedures. Further investigations are warranted to determine whether this increased risk is modifiable, with the aim of improving patient safety.

Obstructive Sleep Apnea Is an Independent Predictor of Postoperative Atrial Fibrillation in Cardiac Surgery.

OBJECTIVE: To test the hypothesis that obstructive sleep apnea (OSA) is a risk factor for development of postoperative atrial fibrillation (POAF) after cardiac surgery. DESIGN: Retrospective analysis. SETTING: Single-center university hospital. PARTICIPANTS: Five hundred forty-five patients in sinus rhythm preoperatively undergoing coronary artery bypass grafting (CABG), aortic valve replacement, mitral valve replacement/repair, or combined valve/CABG surgery from January 2008 to April 2011. INTERVENTIONS: Retrospective review of medical records. MEASUREMENTS AND MAIN RESULTS: Postoperative atrial fibrillation was defined as atrial fibrillation requiring therapeutic intervention. Of 545 cardiac surgical patients, 226 (41%) patients developed POAF. The risk was higher in 72 OSA patients than 473 patients without OSA (67% v 38%, adjusted hazard ratio 1.83 [95% CI: 1.30-2.58], p<0.001). Of the 32 OSA patients who used home positive airway pressure (PAP) therapy, 18 (56%) developed POAF compared with 29 of 38 (76%) patients who did not use PAP at home (unadjusted hazard ratio 0.63 [95% CI: 0.35-1.15], p = 0.13). CONCLUSION: OSA is significantly associated with POAF in cardiac surgery patients. Further investigation is needed to determine whether or not use of positive airway pressure in OSA patients reduces the risk of POAF.

Pulmonary vascular resistance index and mortality after paediatric heart transplant.

BACKGROUND: Although some prior studies have provided evidence to question the historical belief that pulmonary vascular resistance index ⩾6 Wood Units×m2 should be a contraindication to heart transplantation in children, no national analyses specific to the modern area have addressed this question. METHODS: Data were analysed for paediatric heart transplant recipients from 1 January, 2002 to 1 September, 2012 (n=699). The relationship between pulmonary vascular resistance and all-cause 30-day mortality was evaluated using univariate and multivariate analyses. RESULTS: The 30-day mortality included 10 patients (1.43%), which is lower than in the previous analyses. Receiver operating curve analysis of pulmonary vascular resistance index as a predictor of mortality yielded a cut-off value of 3.37 Wood Units×m2, but the area under the curve and specificity of this threshold was weaker than in previous analyses. Whereas pulmonary vascular resistance index treated as a dichotomised variable was a significant predictor of mortality in univariate (odds ratio 4.92, 95% confidence interval 1.04-23.33, p=0.045) and multivariate (odds ratio 5.26, 95% confidence interval 1.07-25.80, p=0.041) analyses, pulmonary vascular resistance index treated as a continuous variable was not a significant predictor of mortality in univariate (p=0.12) or multivariate (p=0.11) analyses. CONCLUSIONS: The relationship between pulmonary vascular resistance and post-heart transplant mortality in children is less convincing in this analysis of a comprehensive, contemporary database than in previous series. This suggests the possibility that modern improvements in the management of post-transplant right ventricular dysfunction have mitigated the contribution of pulmonary hypertension to early mortality.

Percutaneous tracheostomy at the bedside: 13 tips for improving safety and success.

We have developed a set of routines and practices in the course of performing a large series (n = 70) of percutaneous dilational tracheostomy (PDT). The 13 tips discussed in this review fall into 4 categories. System factors that facilitate training, patient safety, and avoidance of crises including the use of appropriate personnel, importance of timing, use of premedication, and the utility and content of a preprocedure briefing. Suggestions to prevent loss of the airway include tips on airway assessment, preparation of airway equipment, and use of exchange catheter techniques. Strategies to avoid and manage both microvascular and large-vessel bleeding are discussed. We also discuss the management of common postprocedure problems including tracheostomy tube obstruction, malposition requiring tube exchange or replacement, and air leak. The practical considerations for successful execution of PDT involve common sense, thorough planning, and structured approaches to prevent adverse effects if the procedure does not go as smoothly as expected. These strategies will aid anesthesiologists and intensivists in improving their comfort level, safety, and competence in performing this beside procedure.

Congenital anomalies of the aortic arch in acute type-a aortic dissection: implications for monitoring, perfusion strategy, and surgical repair.

OBJECTIVE: To assess whether management of acute Stanford type-A aortic dissection differs in patients with congenital anomalies of the aortic arch compared with standard institutional practice. DESIGN: Retrospective analysis of all consecutive patients from 2001 through 2011. SETTING: Quaternary referral center for surgical management of thoracic aortic disease. PARTICIPANTS: All patients with arch anomalies who underwent surgery for acute Stanford type-A aortic dissection during the study period (n = 43). INTERVENTIONS: Surgical management, anesthetic monitoring, and perfusion strategy were analyzed in a retrospective fashion. No new interventions were undertaken as part of this study. MEASUREMENTS AND MAIN RESULTS: Management differed most in patients with an aberrant right subclavian artery (n = 5), because the institutional standard of right axillary artery cannulation with left upper extremity arterial pressure monitoring was not possible. In patients with one of two "bovine" arch patterns (n = 32), management differed in the conduct of selective antegrade cerebral perfusion, which could include clamping above or below the takeoff of the left common carotid artery (and, therefore, produced unilateral or bilateral antegrade cerebral perfusion). All patients with a connective tissue disorder exhibited a bovine arch pattern. Management of patients with a right arch (n = 3) reflected the opposite of management for normal anatomy (for patients with traditional mirror-image branching) or opposite that of the aberrant right subclavian group (for patients who had a corresponding aberrant left subclavian artery). CONCLUSIONS: Rational management reflected the anatomic variations observed. These results support the importance of interdisciplinary planning, especially in an emergency, to optimize outcome.

P-wave characteristics on routine preoperative electrocardiogram improve prediction of new-onset postoperative atrial fibrillation in cardiac surgery.

OBJECTIVE: To test the hypothesis that including preoperative electrocardiogram (ECG) characteristics with clinical variables significantly improves the new-onset postoperative atrial fibrillation prediction model. DESIGN: Retrospective analysis. SETTING: Single-center university hospital. PARTICIPANTS: Five hundred twenty-six patients, ≥ 18 years of age, who underwent coronary artery bypass grafting, aortic valve replacement, mitral valve replacement/repair, or a combination of valve surgery and coronary artery bypass grafting requiring cardiopulmonary bypass. INTERVENTIONS: Retrospective review of medical records. MEASUREMENTS AND MAIN RESULTS: Baseline characteristics and cardiopulmonary bypass times were collected. Digitally-measured timing and voltages from preoperative electrocardiograms were extracted. Postoperative atrial fibrillation was defined as atrial fibrillation requiring therapeutic intervention. Two hundred eight (39.5%) patients developed postoperative atrial fibrillation. Clinical predictors were age, ejection fraction<55%, history of atrial fibrillation, history of cerebral vascular event, and valvular surgery. Three ECG parameters associated with postoperative atrial fibrillation were observed: Premature atrial contraction, p-wave index, and p-frontal axis. Adding electrocardiogram variables to the prediction model with only clinical predictors significantly improved the area under the receiver operating characteristic curve, from 0.71 to 0.78 (p<0.01). Overall net reclassification improvement was 0.059 (p = 0.09). Among those who developed postoperative atrial fibrillation, the net reclassification improvement was 0.063 (p = 0.03). CONCLUSION: Several p-wave characteristics are independently associated with postoperative atrial fibrillation. Addition of these parameters improves the postoperative atrial fibrillation prediction model.

Perioperative outcomes of major noncardiac surgery in adults with congenital heart disease.

BACKGROUND: An increasing number of patients with congenital heart disease are surviving to adulthood. Consensus guidelines and expert opinion suggest that noncardiac surgery is a high-risk event, but few data describe perioperative outcomes in this population. METHODS: By using the Nationwide Inpatient Sample database (years 2002 through 2009), the authors compared patients with adult congenital heart disease (ACHD) who underwent noncardiac surgery with a non-ACHD comparison cohort matched on age, sex, race, year, elective or urgent or emergency procedure, van Walraven comborbidity score, and primary procedure code. Mortality and morbidity were compared between the two cohorts. RESULTS: A study cohort consisting of 10,004 ACHD patients was compared with a matched comparison cohort of 37,581 patients. Inpatient mortality was greater in the ACHD cohort (407 of 10,004 [4.1%] vs. 1,355 of 37,581 [3.6%]; unadjusted odds ratio, 1.13; P = 0.031; adjusted odds ratio, 1.29; P < 0.001). The composite endpoint of perioperative morbidity was also more commonly observed in the ACHD cohort (2,145 of 10.004 [21.4%] vs. 6,003 of 37,581 [16.0%]; odds ratio, 1.44; P < 0.001). ACHD patients comprised an increasing proportion of all noncardiac surgical admissions over the study period (P value for trend is <0.001), and noncardiac surgery represented an increasing proportion of all ACHD admissions (P value for trend is <0.001). CONCLUSIONS: Compared with a matched control cohort, ACHD patients undergoing noncardiac surgery experienced increased perioperative morbidity and mortality. Within the limitations of a retrospective analysis of a large administrative dataset, this finding demonstrates that this is a vulnerable population and suggests that better efforts are needed to understand and improve the perioperative care they receive.

SARS-Co-V-2 positive status is associated with a more seriously injured population of trauma patients but not independently associated with worse outcomes of trauma care.

BACKGROUND: SARS-CoV-2 positive status has been considered a predominantly incidental finding among trauma patients. We sought to examine whether concurrent infection is associated with worse outcomes in a contemporary cohort of injured patients during the COVID-19 pandemic. METHODS: Retrospective cohort analysis of a level I trauma center's institutional registry from May 1, 2020 through June 30, 2021. The prevalence of COVID in the trauma population was compared monthly using prevalence ratios relative to population estimates. Unadjusted cohorts of COVID+ vs COVID- trauma patients were compared. COVID+ patients then were matched on age, mechanism of injury, year, and injury severity score (ISS) with COVID- controls for adjusted analysis with a primary composite outcome of mortality. RESULTS: Out of n=2,783 trauma activations, n=51 (1.8%) were COVID+. Compared to the general population, the trauma population had prevalence ratios for COVID of 5.3 to 79.7 (median=20.8). Compared to COVID- patients, COVID+ patients had worse outcomes, including a higher proportion who were admitted to the ICU, required intubation, underwent a major operation, and had greater total charges and a longer length of stay. However, these differences appeared related to more severe injury patterns in the COVID+ cohort. In the adjusted analysis, no significant differences between groups in any of the outcome variables were observed. CONCLUSIONS: Worse trauma outcomes in COVID+ patients appear to be correlated to the more substantial patterns of injury observed in this group. Trauma patients have substantially higher rates of SARS-CoV-2 positivity than the local population at large. These results reinforce that this population is vulnerable to multiple threats. They will guide the ongoing delivery of care in shaping the needs for testing, PPE for those delivering care, and the capacity and operational needs of trauma systems that must care for a population with such high rates of SARS-CoV-2 infection.

Perioperative management of the morbidly obese adolescent with heart failure undergoing bariatric surgery.

The incidence and prevalence of adolescent obesity and adolescent heart failure are increasing, and anesthesiologists increasingly will encounter patients with both conditions. A greater understanding of the physiologic challenges of adolescent heart failure as they relate to the perioperative stressors of anesthesia and bariatric surgery is necessary to successfully manage the perioperative risks faced by this growing subpopulation. Here, we present a representative case of a morbidly obese adolescent with heart failure who underwent a laparoscopic bariatric operation and review the limited available literature on perioperative management in this age group. Specifically, we review evidence and offer recommendations related to preoperative evaluation, venous thromboembolism prophylaxis, positioning, induction, airway management, monitoring, anesthetic maintenance, ventilator management, and adverse effects of the pneumoperitoneum, rhabdomyolysis, and postoperative care.

National patterns of injury and outcomes of gunshot wounds to the penis: A Trauma Quality Programs retrospective cohort analysis.

AIM: Gunshot wounds (GSW) to the penis represent a rare type of traumatic injury in the civilian United States population. Although small, single-center studies have reported results of care for these types of injured patients, no national analyses have examined this group. METHODS: A cohort of patients with GSW to the penis was identified using the 2017 American College of Surgeons Trauma Quality Programs database, a comprehensive national database of 753 accredited trauma centers. RESULTS: Gunshot wounds to the penis occurred in 722 patients, which represents 1.7% of all GSW patients (n = 41,017). Gunshot wounds from altercations with law enforcement or accidental discharge of a firearm were rare; the vast majority (n = 655, 90.7%) occurred as a result of assault, intentional self-harm, attempted suicide, or attempted homicide. Patients with a major concomitant non-genitourinary injury comprised 119 (16.5%) patients of the cohort. Most patients (n = 499, 69.1%) underwent a genitourinary procedure during their trauma admission. Penile salvage was successful in most cases, with only 13 (1.8%) patients requiring completion penectomy. Most patients (87.8%) required admission with a median length of stay of 49.8 h. Most patients were treated at the initial trauma center without requiring transfer to another center, and complications during admission were rare. CONCLUSIONS: This analysis, the first national examination of care of patients with GSW to the penis, reveals overall favorable outcomes. Admission and surgical intervention were required in most patients, but penectomy was rare and length of stay was generally short. These results will guide resource utilization and quality improvement efforts in this patient cohort.

Medical Comanagement of Hip Fracture Patients Is Not Associated with Superior Perioperative Outcomes: A Propensity Score-Matched Retrospective Cohort Analysis of the National Surgical Quality Improvement Project.

BACKGROUND: Medical comanagement entails a significant commitment of clinical resources with the aim of improving perioperative outcomes for patients admitted with hip fractures. To our knowledge, no national analyses have demonstrated whether patients benefit from this practice. METHODS: We performed a retrospective cohort analysis of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) targeted user file for hip fracture 2016-2017. Medical comanagement is a dedicated variable in the NSQIP. Propensity score matching was performed to control for baseline differences associated with comanagement. Matched pairs binary logistic regression was then performed to determine the effect of comanagement on the following primary outcomes: mortality and a composite endpoint of major morbidity. RESULTS: Unadjusted analyses demonstrated that patients receiving medical comanagement were older and sicker with a greater burden of comorbidities. Comanagement did not have a higher proportion of patients participating in a standardized hip fracture program (53.6% vs 53.7%; P > .05). Comanagement was associated with a higher unadjusted rate of mortality (6.9% vs 4.0%, odds ratio [OR] 1.79: 1.44-2.22; P < .0001) and morbidity (19.5% vs 9.6%, OR 2.28: 1.98-2.63; P < .0001). After propensity score matching was used to control for baseline differences associated with comanagement, patients in the comanagement cohort continued to demonstrate inferior mortality (OR 1.36: 1.02-1.81; P = .033) and morbidity (OR 1.82: 1.52-2.20; P < .0001). CONCLUSIONS: This analysis does not provide evidence that dedicated medical comanagement of hip fracture patients is associated with superior perioperative outcomes. Further efforts may be needed to refine opportunities to modify the significant morbidity and mortality that persists in this population.

Enhanced recovery and early extubation after pediatric cardiac surgery using single-dose intravenous methadone.

Background/Aims: Methadone may offer advantages in facilitating early extubation after cardiac surgery, but very few data are available in the pediatric population. Setting/Design: Community tertiary children's hospital, retrospective case series. Materials and Methods: We performed a retrospective analysis of all pediatric cardiac surgical patients for whom early extubation was intended. A multimodal analgesic regimen was used for all patients, consisting of methadone (0.2-0.3 mg/kg), ketamine (0.5 mg/kg plus 0.25 mg/kg/h), lidocaine (1 mg/kg plus 1.5 mg/kg/h), acetaminophen (15 mg/kg), and parasternal ropivacaine (0.5 mL/kg of 0.2%). Outcome variables were collected with descriptive statistics. Results: A total of 24 children [median = 7 (interquartile range = 3.75-13.75) years old, 23.7 (14.8-53.4) kg] were included in the study; 22 (92%) had procedures performed on bypass and 11 (46%) involved a reentry sternotomy. Methadone dosing was 0.26 (0.23-0.29) mg/kg. None of the children required intraoperative supplemental opioids; 23 (96%) were extubated in the operating room. The first paCO2 on pediatric intensive care unit admission was 51 (45-58) mmHg. Time to first supplemental opioid administration was 5.1 (3.5-9.5) h. Cumulative total supplemental opioids (in intravenous morphine equivalents) at 24 and 72 h were 0.2 (0.09-0.32) and 0.42 (0.27-0.68) mg/kg. One child required postoperative bilevel positive airway pressure support, but none required reintubation. None had pruritus; three (13%) experienced nausea. Conclusion: A methadone-based multimodal regimen facilitated early extubation without appreciable adverse events. Further investigations are needed to confirm efficacy of this regimen and to assess whether the excellent safety profile seen here holds in the hands of multiple providers caring for a larger, more heterogeneous population.

Pregnant trauma patients may be at increased risk of mortality compared to nonpregnant women of reproductive age: trends and outcomes over 10 years at a level I trauma center.

BACKGROUND: Pregnancy has been identified as a risk factor for poor outcomes after traumatic injury, but prior outcome analyses are conflicting and dated. We sought to examine outcomes in a contemporary cohort. METHODS: Retrospective cohort analysis at a level I trauma center's institutional registry from 2009 to 2018, with comparison to population-level demographic trends in women of reproductive age and pregnancy prevalence. Unadjusted cohorts of pregnant versus nonpregnant trauma patients were compared. Pregnant patients then were matched on age, mechanism of injury, year, and injury severity score with nonpregnant controls for adjusted analysis with a primary outcome of maternal mortality. RESULTS: Despite declining birth and pregnancy rates in the population, pregnant women comprised a stable 5.3% of female trauma patients of reproductive age without decline over the study period (p = 0.53). Compared with nonpregnant women, pregnant trauma patients had a lower injury severity score (1 [1-5] vs 5 [1-10] p < 0.0001) and a shorter length of stay (1 [1-2] vs 1 [1-4] p = 0.04), were less likely to have CT imaging (48.8% vs 67.4%, p < 0.0001) and more likely to be admitted (89.3% vs 79.2%, p = 0.003). Positive toxicology screens were less prevalent in pregnant women, but only for ethanol (5.4% vs 31.4%, p < 0.0001); there was no difference in rates of cannabis, opiates, or cocaine. After matching to adjust for age, year, mechanism of injury, and injury severity score, mortality occurred significantly more frequently in the pregnant cohort (2.1% vs 0.2%, OR = 13.5 [1.39-130.9], p = 0.02). CONCLUSION: Pregnant trauma patients have not declined in our population despite population-level declines in pregnancy. After adjusting for lower injury severity, pregnant women were at substantially greater risk of mortality. This supports ongoing concern for pregnant trauma patients as a vulnerable population. Further efforts should optimize systems of care to maximize the chances of rescue for both mother and fetus.

Rotational thromboelastometry predicts transfusion and disability in pediatric trauma.

BACKGROUND: Trauma-induced coagulopathy seen on rotational thromboelastometry (ROTEM) is associated with poor outcomes in adults; however, this relationship is poorly understood in the pediatric population. We sought to define thresholds for product-specific transfusion and evaluate the prognostic efficacy of ROTEM in injured children. METHODS: Demographics, ROTEM, and clinical outcomes from severely injured children (age, < 18 years) admitted to a Level I trauma center between 2014 and 2018 were retrospectively analyzed. Receiver operating characteristic curves were plotted and Youden indexes were calculated against the endpoint of packed red blood cell transfusion to identify thresholds for intervention. The ROTEM parameters were compared against the clinical outcomes of mortality or disability at discharge. RESULTS: Ninety subjects were reviewed. Increased tissue factor-triggered extrinsic pathway (EXTEM) clotting time (CT) >84.5 sec (p = 0.049), decreased EXTEM amplitude at 10 minutes (A10) <43.5 mm (p = 0.025), and decreased EXTEM maximal clot firmness (MCF) <64.5 mm (p = 0.026) were associated with need for blood product transfusion. Additionally, EXTEM CT longer than 68.5 seconds was associated with mortality or disability at discharge. CONCLUSION: Coagulation dysregulation on thromboelastometry is associated with disability and mortality in children. Based on our findings, we propose ROTEM thresholds: plasma transfusion for EXTEM CT longer than 84.5 seconds, fibrinogen replacement for EXTEM A10 less than 43.5 mm, and platelet transfusion for EXTEM MCF less than 64.5 mm. LEVEL OF EVIDENCE: Prognostic, Level III; Therapeutic, Level IV.