A deep dive into the FEISTY Junior study and its impact on paediatric major haemorrhage protocols.

Speaker biography:

Assoc. Prof. Shane George is an Emergency and Paediatric Intensive Care Physician at Gold Coast University Hospital.

He is an active clinician researcher with focuses on topics that span both emergency medicine and PICU practice including safety in emergency intubation, sepsis, haemostatic resuscitation in children and respiratory support therapies.

Insights:

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Paediatric major haemorrhage is rare, high-stakes, and persistently difficult to manage — largely because existing protocols are adapted from adult trauma rather than built for children. Shane George outlines why terminology has shifted from massive transfusion protocols to major haemorrhage protocols: to re-centre clinicians on the real problem (haemorrhage), reduce subjectivity, and avoid reflexively “giving a bit of everything.” Despite progress in adults, paediatric practice still lags in adopting viscoelastic assays (ROTEM/TEG/ClotPro) due to low case frequency, limited familiarity, and the cognitive load of interpreting results during resuscitation.

Emerging US consensus guidelines now recommend goal-directed resuscitation using viscoelastic assays—marking the first paediatric-specific endorsement of targeted product replacement. The Gold Coast has been an early adopter, using ROTEM-guided algorithms for nearly a decade. Local audit data showed that although ROTEM was under-used, 70% of those tested had clinically significant abnormalities, reinforcing its value.

The FEISTY Junior (Fibrinogen Early In Severe Paediatric Trauma) study explored whether clinicians can identify low fibrinogen early, how quickly fibrinogen can be replaced, and whether viscoelastic-guided therapy is feasible. Clinician gestalt plus early transfusion proved a good predictor of low fibrinogen. Unexpectedly, time to deliver cryoprecipitate matched fibrinogen concentrate. The study supports routine viscoelastic testing for any child receiving blood, targeted fibrinogen replacement, and ongoing algorithm refinement to reduce delays and under-recognition of coagulopathy.

Key Insights

• Language shapes behaviour: Moving from “massive transfusion” to “major haemorrhage” reduces subjective thresholds and centres clinicians on fixing the haemorrhage, not simply administering products.
• Adult evidence ≠ paediatric evidence: Many paediatric protocols are extrapolated; children bleed differently, coagulopathies behave differently, and fibrinolysis is more common.
• Viscoelastic assays are underused but high-yield: Even infrequently performed tests revealed abnormalities in 70% of children—suggesting many coagulopathies go undetected.
• Goal-directed resuscitation is coming: For the first time, paediatric guidelines recommend targeted product replacement based on ROTEM/TEG, not fixed “packs.”
• Predicting low fibrinogen is possible: Clinician concern + early red-cell transfusion strongly correlates with low fibrinogen on arrival.
• System issues matter: Faster fibrinogen delivery should be achievable; identical delivery times for cryo and concentrate point to process constraints, not product limitations.
• Continuous reassessment is essential: Repeat viscoelastic testing after every intervention drives more accurate replacement and avoids overtreating or undertreating.

Practical Recommendations

• Adopt “major haemorrhage” terminology to standardise thresholds and shift thinking toward problem-focused care.
• Use viscoelastic assays early in any child receiving transfusion; integrate ROTEM/TEG into major haemorrhage protocols where available.
• Move toward goal-directed resuscitation rather than fixed product packs; replace what is truly deficient.
• Train the whole team—low case frequency demands simulation, cheat-sheets, and cognitive offloading tools to support interpretation.
• Develop a local fibrinogen strategy: know which product is fastest in your institution, and establish a protocol for empiric replacement if testing is delayed.
• Re-test after every intervention to guide dosing and avoid cumulative product overload.
• Audit regularly—track time to ROTEM, time to fibrinogen, and protocol adherence to identify system barriers.