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High ratio plasma resuscitation does not improve survival in pediatric trauma patients
Jeremy W Cannon1, Michael A Johnson, Robert C Caskey
1From the Division of Traumatology, Surgical Critical Care & Emergency Surgery (J.W.C.) and the Department of Surgery (R.C.C.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; David Grant Medical Center (J.W.C.), Travis Air Force Base, Fairfield, California; Uniformed Services (J.W.C., M.A.B.), University of the Health Sciences, Bethesda, Maryland; Department of Emergency Medicine (M.A.J.), University of California, Davis, California; Department of Pediatrics (M.A.B.), San Antonio Military Medical Center, Fort Sam Houston, San Antonio, Texas; and Department of Pediatric Surgery (L.P.N.), Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia.
Insights
High plasma ratios in pediatric trauma resuscitation did not improve survival. Further research is needed to find optimal strategies for critically injured children receiving massive transfusions.
Area of Science:
- Trauma Resuscitation
- Pediatric Critical Care
- Blood Product Transfusion
Background:
- Damage control resuscitation with high plasma (PLAS) and platelet (PLT) to packed red blood cell (PRBC) ratios improves survival in adults.
- The effectiveness of this high PLAS/PRBC ratio strategy in pediatric combat casualties was evaluated.
Purpose of the Study:
- To assess the impact of a high plasma to packed red blood cell ratio resuscitation strategy on survival in massively transfused pediatric patients with combat injuries.
Main Methods:
- Retrospective analysis of the Department of Defense Trauma Registry (2001-2013) for pediatric trauma patients (<18 years) receiving massive transfusion (≥40 mL/kg in 24 hours).
- Exclusion of specific injury types (burns, drowning, isolated head trauma) and older adolescents.
- Evaluation of mortality at 24 hours and hospital discharge, alongside secondary outcomes like blood product utilization and length of stay.
Main Results:
- Analysis of 364 pediatric patients revealed no clear inflection point for mortality based on PLAS/PRBC ratios.
- No significant difference in all-cause mortality at 24 hours (9.2% vs. 8.0%) or hospital discharge (21.5% vs. 17.1%) between low and high PLAS/PRBC ratio groups.
- High ratio group received more PLAS and PLT but had a longer hospital stay; regression analysis showed no mortality benefit (HR, 2.04; P = 0.34).
Conclusions:
- A high plasma to packed red blood cell ratio was not associated with improved survival in combat-injured children undergoing massive transfusion.
- Prospective studies are necessary to determine the optimal resuscitation strategy for critically injured pediatric patients.
Background:
Damage control resuscitation including balanced resuscitation with high ratios of plasma (PLAS) and platelets (PLT) to packed red blood cells (PRBC) improves survival in adult patients. We sought to evaluate the effect of a high ratio PLAS to PRBC resuscitation strategy in massively transfused pediatric patients with combat injuries.
Methods:
The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric trauma patients (<18 years). Burns, drowning, isolated head trauma, and older teens were excluded. Those who received massive transfusion (≥40 mL/kg total blood products in 24 hours) and early deaths who received any blood products were then evaluated. Primary outcomes were mortality at 24 hours and in-hospital. Secondary outcomes included blood product utilization over 24 hours, ventilator-free days, intensive care unit-free days, and hospital length of stay.
Results:
The Department of Defense Trauma Registry yielded 4,980 combat-injured pediatric trauma patients, of whom 364 met inclusion criteria. Analysis of PLAS/PRBC ratios across the entire spectrum of possible ratios in these patients demonstrated no clear inflection point for mortality. Using a division between low (LO) and high (HI) ratios of PLAS/PRBC 1:2, there was no difference in all-cause mortality at 24 hours (LO, 9.2% vs. HI, 8.0%; p = 0.75) and hospital discharge (LO, 21.5% vs. HI, 17.1%; p = 0.39). HI ratio patients received less PRBC but more PLAS and PLT and more total blood products. Those in the HI ratio group also had longer hospital length of stay. Regression analysis demonstrated no associated mortality benefit with a HI ratio (hazards ratio, 2.04; 95% confidence interval, 0.48-8.73; p = 0.34).
Conclusion:
In combat-injured children undergoing a massive transfusion, a high ratio of PLAS/PRBC was not associated with improved survival. Further prospective studies should be performed to determine the optimal resuscitation strategy in critically injured pediatric patients.
Level Of Evidence:
Therapeutic study, level III.
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