M. E. Cunningham1, E. H. Rosenfeld1, B. Naik-Mathuria1, R. T. Russell2, A. M. Vogel1 1Baylor College Of Medicine,Department Of Pediatric Surgery,Houston, TX, USA 2Children’s Hospital Of Alabama,Department Of Pediatric Surgery,Birmingham, AL, USA
Introduction: Massive transfusion protocols (MTP) with balanced high blood product ratios (plasma and platelets to red blood cells (RBC)) have been associated with improved outcomes in adult trauma. Their impact in pediatric trauma is unclear. The purpose of this study is to evaluate the effect of blood product ratios in severely injured children.
Methods: The 2015-2016 American College of Surgeons Trauma Quality Improvement Program research dataset was used to identify trauma patient’s ≤ 18 years of age who received a massive transfusion (≥40ml/kg/24-hours total blood products). Children with burns and non-survivable injuries were excluded. Plasma:RBC and platelet:RBC ratios were categorized into low (<1:2), medium (≥1:2 to <1:1), and high (≥1:1). Trauma-related clinical and outcome data was collected and analyzed using descriptive statistics, Kruskal-wallis test, Chi-Square, Fisher’s exact test, and Kaplan-Meier analysis. Continuous variables are presented as median [IQR]; p<0.05 is significant.
Results:Of 473 patients, the median age was 9 [3,16] years, 159 (34%) were female, and 350 (74%) were blunt injuries. Gender, mechanism of injury, ISS, GCS, and age-adjusted vitals were similar amongst the low, medium, and high plasma:RBC and platelet:RBC cohorts. Children in the low plasma:RBC group were younger compared to those in the medium and high groups (6 [2,13] vs 13 [6,17] & 12 [6,17]; p<0.01). Analysis of the plasma:RBC groups showed those with low ratios had a lower incidence of acute kidney injury (AKI) (0% vs 4% & 5%; p=0.01) compared to medium and high ratios, and fewer ventilator-free days (6 [0,23] vs 17 [17,23]; p=0.03) compared to high ratios. Those with medium plasma:RBC ratios had greater total blood transfusion volumes (ml/kg/24-hours) (89 [56,156] vs 68 [50,105] & 69 [50,115]; p<0.01). There was no difference in ICU-free days or other in-hospital complications between the groups. Analysis of the platelet:RBC ratios showed no significant difference in total blood volume received, ventilator free-days, ICU-free days, AKI, or other in-hospital complications. Hemorrhage control procedures were less common in the low plasma:RBC cohort (34% vs: 56% & 51%; p<0.01), while there was no difference between the platelet:RBC cohorts. Survival was improved in the high plasma:RBC cohort early on (Fig. 1), but became insignificant as time passed. There was no improvement in survival between the platelet:RBC cohorts at any time.
Conclusion: A high ratio of plasma:RBC may result in improved early survival in injured children receiving a massive transfusion. Prospective, multicenter studies are needed to determine optimal resuscitation strategies for these critically ill children.
