Table 2.

List of statements accepted by Delphi survey round. (R1 = Round 1, R2 = Round 2, R3 = Round 3, R4 = Round 4)

Accepted Statements by Round		% of panelists who accept per round
Round 1
The optimal resuscitative strategy in a hypotensive child with signs of head injury who arrives to the trauma room with potential ongoing bleeding is:	Crystalloid administration to attempt restoration of normotension while awaiting blood products.	87.9%
During massive transfusion, the following laboratory values should be performed at baseline:	CBC	94.1%
	Chem 7	82.1%
	Type and Screen	100%
	PT/PTT/INR	94.1%
The following laboratory values should be monitored periodically during the course of ongoing massive transfusion:	CBC	94.1%
	PT/PTT/INR	94.1%
	Fibrinogen Level	91.2%
The following laboratory values should be monitored at the conclusion of a massive transfusion:	CBC	94.1%
	Chem 7	82.4%
	PT/PTT/INR	88.2%
	Fibrinogen	91.2%
Round 2
In pediatric trauma, a hemodynamically stable child without symptoms of anemia who is at low risk for bleeding should receive blood transfusion to have their hemoglobin maintained at, or above:	6 g/dL	R1 – 71.4% R2 – 80.0%
In pediatric trauma, a hemodynamically stable child with symptoms of anemia who is at low risk for bleeding should receive blood transfusion to have their hemoglobin maintained at, or above1:	7 g/dL	R1 – 94.3% R2 – 80.0%
A hemodynamically stable child at high risk for bleeding should have their platelet count maintained at or above:	50,000/microL	R1 – 77.1% R2 – 88.6%
A hemodynamically stable child with an average risk of bleeding should have their platelet count maintained at or above:	20,000/microL	R1 – 74.3% R2 – 85.7%
A hemodynamically stable child at high risk for bleeding should have their INR maintained at or below:	2.0	R1 – 64.7% R2 – 80.0%
A hemodynamically stable child at average risk of bleeding should have their INR maintained at or below:	2.0	R1 – 61.8% R2 – 90.9%
What defines “massive transfusion” in children?	The administration of blood products equaling one or more blood volume in 24 hours or one half a blood volume in 12 hours.	R1 – 70.6% R2 – 85.7%
During massive transfusion, the following laboratory values should be performed at baseline:	Lactate	R1 – 70.6% R2 – 82.4%
	Fibrinogen	R1 – 73.5% R2 – 82.4%
	Point of care testing ABG or VBG + Expanded lab assessment including chemistry, hemoglobin/hematocrit and lactate	R1 – 64.7% R2 – 88.2%
The following laboratory values should be monitored periodically during the course of ongoing massive transfusion:	Chem 7	R1 – 79.4% R2 – 85.3%
	Lactate	R1 – 67.6% R2 – 85.3%
	Point of care testing ABG or VBG + Expanded lab assessment including chemistry, hemoglobin/hematocrit and lactate	R1 – 61.8% R2 – 94.1%
The following laboratory values should be monitored at the conclusion of a massive transfusion:	Lactate	R1 – 67.6% R2 – 85.3%
	Point of care testing ABG or VBG + Expanded lab assessment including chemistry, hemoglobin/hematocrit and lactate	R1 – 50.0% R2 – 88.2%
Round 3
The optimal resuscitative strategy in a hypotensive child without signs of head injury who arrives to the trauma room with potential ongoing bleeding is:	Crystalloid administration to attempt restoration of normotension while awaiting blood products.	R1 – 57.6% R2 – 68.6% R3 – 94.3%
In a hemodynamically unstable child with potential ongoing bleeding, the most appropriate first step in resuscitation is2:	20mL/kg crystalloid solution	R1 – 55.9% R2 – 77.1% R3 – 97.1%
Under what circumstances should the pediatric massive transfusion protocol be activated?	Anticipation of transfusion of > 70mL/kg any blood product	R1 – 58.8% R2 – 61.8% R3 – 80.0%
	Anticipation of transfusion of a blood volume in 24 hours.	R1 – 67.6% R2 – 70.6% R3 – 88.6%
During massive transfusion of a bleeding child, packed red blood cells (PRBC) should be given in the following ratio in relation to fresh frozen plasma (FFP):	2:1 ratio by volume to simulate blood product activity/ratios found in whole blood	R1 – 55.9% R2 – 64.7% R3 – 80.0%
During massive transfusion of a bleeding child, platelets should be administered:	After every round of PRBC and FFP	R1 – 47.1% R2 – 67.6% R3 – 80.0%
During massive transfusion of a bleeding child, platelets should be given in the following ratio with PRBC and FFP3:	1:1:1 ratio in an attempt to simulate the activity/ratios present in whole blood – lower platelet volume.	R1 – 50.0% R2 – 70.6% R3 – 82.9%
During massive transfusion of a bleeding child, cryoprecipitate should be administered:	When the fibrinogen level is < 100mg/dL	R1 – 47.1% R2 – 73.5% R3 – 88.6%
At a minimum, point of care testing (Ideally ABG or VBG/Chemistry/Hemoglobin/Hematocrit/Lactate) during massive transfusion should be performed every:	1 hour	R1 – 47.1% R2 – 76.5% R3 – 94.3%
Round 4
Under what circumstances should the pediatric massive transfusion protocol be activated?:	Anticipation of emergency transfusion of > 40mL/kg of any blood product.	R1 – 52.9% R2 – 70.6% R3 – 74.3% R4 – 97.1%
Under what circumstances should the pediatric massive transfusion protocol be activated?:	After emergency transfusion of > 40mL/kg of any blood product.	R1 – 64.7% R2 – 61.8% R3 – 51.4% R4 – 100%
Your patient remains hypotensive after your initial intervention. In a hemodynamically unstable child with potential ongoing bleeding, the most appropriate second step in resuscitation is: #	20mL/kg PRBC	R1 – 32.4% R2 – 42.9% R3 – 71.4% R4 – 94.3%

¹This statement was re-rated in round 2 – see text.

²This statement was accepted with caveats given on the end of Delphi teleconference. Rejecting the concept of permissive hypotension for children, hypotensive children should receive resuscitation with whatever fluid is immediately available. If blood is immediately available, then it should be given first (also see round 4 statement marked with #).

³This is rectified with the statement above in the discussion section. A 1:1:1 ratio of PRBC:FFP:Platelets to simulate the activity found in whole blood was determined to be 2:1:0.3–0.5 by volume.