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Time-limited association between plasma transfusion and mortality in pediatric traumatic brain injury
Leah Furman1, Erin V Feeney, Barbara A Gaines
1From the Department of Surgery (L.F., E.V.F.), University of Pittsburgh Medical Center; Trauma and Transfusion Medicine Research Center (L.F., E.V.F., C.M.L.), University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pediatric Surgery, Department of Surgery (B.A.G.), University of Texas Southwestern Medical Center, Dallas, Texas; and Department of Surgery and Critical Care Medicine (C.M.L.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Insights
Early plasma transfusion in children with severe traumatic brain injury (TBI) was associated with a reduced risk of death within 4 hours. This survival benefit did not extend beyond 24 hours, suggesting a critical window for intervention.
Area of Science:
- Pediatric critical care
- Trauma surgery
- Emergency medicine
Background:
- Traumatic brain injury (TBI) is a leading cause of death in children.
- Prehospital plasma transfusion in adults with TBI is linked to lower mortality.
- The effect of early plasma administration on pediatric TBI outcomes is not well understood.
Purpose of the Study:
- To investigate the impact of early plasma transfusion on mortality in children with severe TBI.
- To determine if early plasma administration affects 4-hour, 24-hour, and 30-day mortality rates.
- To evaluate the association between plasma resuscitation and survival in pediatric severe TBI.
Main Methods:
- Retrospective cohort study using the National Trauma Data Bank (2020-2022).
- Included children aged 1-17 years with severe TBI (head AIS scores 4-5).
- Analyzed plasma transfusion within 4 hours of arrival using Cox proportional hazard models, adjusting for multiple clinical factors.
Main Results:
- 1,594 (10.9%) of 14,691 eligible children received early plasma.
- Early plasma administration was associated with a significantly lower risk of 4-hour mortality (HR=0.610, p=0.005).
- This association with reduced mortality did not persist at 24 hours (HR=0.894) or 30 days (HR=1.132).
Conclusions:
- Early plasma transfusion in pediatric severe TBI is linked to a significant reduction in 4-hour mortality.
- The survival benefit of early plasma appears limited to the initial 4-hour period.
- Further prospective research is necessary to confirm these findings and guide clinical practice.
Background:
Traumatic brain injury (TBI) is a predominant cause of pediatric mortality. While prehospital plasma administration has been associated with lower mortality in adults with TBI, the impact of early plasma in children is unknown.
Methods:
In this retrospective cohort study, we examined the impact of plasma transfusion within 4 hours of arrival on 4-hour, 24-hour, and 30-day mortality in children aged 1 to 17 years with severe TBI (head Abbreviated Injury Scale scores 4 and 5) using the National Trauma Data Bank from 2020 to 2022. We excluded subjects with mild-moderate or nonsurvivable TBI or missing plasma or weight data. Cox proportional hazard models, clustered by facility, assessed the effect of early plasma on mortality, adjusting for: age; sex; trauma mechanism; interfacility transfer; shock; total Glasgow Coma Scale; Injury Severity Score; trauma center level; insurance; binary whole blood, red blood cell, and platelet administration; and weight-adjusted total 4-hour transfusion volumes.
Results:
Of 367,065 children in the National Trauma Data Bank from 2020 to 2022, 14,691 met the inclusion criteria, of whom 1,594 (10.9%) received early plasma. Subjects were mostly male (67.8%), with a median (interquartile range) age of 12 (5-15) years, Glasgow Coma Scale score of 11 (3-15), Injury Severity Score of 25 (17-29), and 28.7% presenting in shock. The adjusted hazard ratio (HR) for the effect of plasma administration on mortality was 0.610 (95% CI, 0.430-0.864; p = 0.005) at 4 hours, 0.894 (95% CI, 0.706-1.131; p = 0.350) at 24 hours, and 1.132 (95% CI, 0.961-1.334; p = 0.138) at 30 days.
Conclusion:
This study reports a significant association between early plasma administration and a lower risk of 4-hour mortality among children with severe TBI that does not persist at or beyond 24 hours. While these data suggest that plasma resuscitation may extend the window for lifesaving intervention, additional prospective data are needed.
Level Of Evidence:
Therapeutic/Care Management; Level III.
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