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Published on: November 8, 2024
Transfusion Ratios and Deficits in Injured Children With Life-Threatening Bleeding
Philip C Spinella1, Julie C Leonard2, Callie Marshall3
1Department of Surgery, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
Insights
In critically injured children, a higher plasma to red blood cell ratio may improve survival. Deficits in plasma and platelet resuscitation are linked to increased mortality, suggesting a need for balanced transfusion strategies.
Area of Science:
- Pediatric critical care medicine
- Trauma resuscitation
- Hemorrhagic shock management
Background:
- Life-threatening bleeding in children requires timely and effective resuscitation.
- The optimal balance of blood products, specifically plasma and platelets relative to red blood cells, is not well-defined in pediatric trauma.
- Understanding the impact of product deficits is crucial for improving outcomes.
Purpose of the Study:
- To evaluate the association between plasma and platelet ratios and deficits with survival in injured children experiencing life-threatening bleeding.
- To determine if specific resuscitation ratios or product deficits correlate with mortality in this vulnerable population.
Main Methods:
- Secondary analysis of a prospective observational study (MAST) involving 191 children with severe bleeding.
- Weight-adjusted blood product volumes (plasma:RBC and platelet:RBC ratios) and calculated deficits were analyzed.
- Statistical adjustments were made for factors including age, injury severity, and medical interventions.
Main Results:
- A high plasma to red blood cell ratio (> 1:2) was associated with improved 6-hour survival (OR = 0.12 [0.03-0.52], p = 0.004).
- Increased plasma deficits correlated with higher 6-hour and 24-hour mortality (p=0.04 and p=0.01, respectively).
- Greater platelet deficits were linked to increased 24-hour mortality (p=0.02).
Conclusions:
- Balanced resuscitation with adequate plasma and platelet administration may enhance early survival in pediatric trauma patients.
- This hypothesis-generating study suggests targeting specific ratios and minimizing deficits could be key to optimal hemostatic resuscitation.
- Further multicenter clinical trials are warranted to confirm these findings and establish best practices.
Objectives:
To assess the impact of plasma and platelet ratios and deficits in injured children with life-threatening bleeding.
Design:
Secondary analysis of the MAssive Transfusion epidemiology and outcomes In Children study dataset, a prospective observational study of children with life-threatening bleeding events.
Setting:
Twenty-four childrens hospitals in the United States, Canada, and Italy.
Patients:
Injured children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under activation of massive transfusion protocol.
Intervention/Exposure:
Weight-adjusted blood product volumes received during the bleeding event were recorded. Plasma:RBC ratio (plasma/RBC weight-adjusted volume in mL/kg) and platelet:RBC ratio (platelet/RBC weight-adjusted volume in mL/kg) were analyzed. Plasma deficit was calculated as RBC mL/kg - plasma mL/kg; platelet deficit was calculated as RBC mL/kg - platelet mL/kg.
Measurements And Main Results:
Of 191 patients analyzed, median (interquartile range) age was 10 years (5-15 yr), 61% were male, 61% blunt mechanism, and median (interquartile range) Injury Severity Score was 29 (24-38). After adjusting for Pediatric Risk of Mortality score, cardiac arrest, use of vasoactive medications, and blunt mechanism, a high plasma:RBC ratio (> 1:2) was associated with improved 6-hour survival compared with a low plasma:RBC ratio (odds ratio [95% CI] = 0.12 [0.03-0.52]; p = 0.004). Platelet:RBC ratio was not associated with survival. After adjusting for age, Pediatric Risk of Mortality score, cardiac arrest, and mechanism of injury, 6-hour and 24-hour mortality were increased in children with greater plasma deficits (10% and 20% increased odds of mortality for every 10 mL/kg plasma deficit at 6 hr [p = 0.04] and 24 hr [p = 0.01], respectively); 24-hour mortality was increased in children with greater platelet deficits (10% increased odds of 24-hr mortality for every 10 mL/kg platelet deficit [p = 0.02)]).
Conclusions:
In injured children, balanced resuscitation may improve early survival according to this hypothesis generating study. Multicenter clinical trials are needed to assess whether clinicians should target ratios and deficits as optimal pediatric hemostatic resuscitation practice.
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