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Association of Blood Component Ratios With 24-Hour Mortality in Injured Children Receiving Massive Transfusion

Butler, Elissa K. MD1,2,3; Mills, Brianna M. PhD1; Arbabi, Saman MD, MPH1,2; Bulger, Eileen M. MD1,2; Vavilala, Monica S. MD1,4; Groner, Jonathan I. MD5,6; Stansbury, Lynn G. MD, MPH1,7; Hess, John R. MD, MPH8; Rivara, Frederick P. MD, MPH1,9

doi: 10.1097/CCM.0000000000003708
Pediatric Critical Care
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Objectives: To determine if higher fresh frozen plasma and platelet to packed RBC ratios are associated with lower 24-hour mortality in bleeding pediatric trauma patients.

Design: Retrospective cohort study using the Pediatric Trauma Quality Improvement Program Database from 2014 to 2016.

Setting: Level I and II pediatric trauma centers participating in the Trauma Quality Improvement Program

Patients: Injured children (≤ 14 yr old) who received massive transfusion (≥ 40 mL/kg total blood products in 24 hr). Of 123,836 patients, 590 underwent massive transfusion, of which 583 met inclusion criteria.

Interventions: None.

Measurements and Main Results: Ratios of fresh frozen plasma:packed RBC and platelet:packed RBC. Of the 583 patients, 60% were male and the median age was 5 years (interquartile range, 2–10 yr). Overall mortality was 19.7% (95% CI, 16.6–23.2%) at 24 hours. There was 51% (adjusted relative risk, 0.49; 95% CI, 0.27–0.87; p = 0.02) and 40% (adjusted relative risk, 0.60; 95% CI, 0.39–0.92; p = 0.02) lower risk of death at 24 hours for the high (≥ 1:1) and medium (≥ 1:2 and < 1:1) fresh frozen plasma:packed RBC ratio groups, respectively, compared with the low ratio group (< 1:2). Platelet:packed RBC ratio was not associated with mortality (adjusted relative risk, 0.94; 95% CI, 0.51–1.71; p = 0.83).

Conclusions: Higher fresh frozen plasma ratios were associated with lower 24-hour mortality in massively transfused pediatric trauma patients. The platelet ratio was not associated with mortality. Although these findings represent the largest study evaluating blood product ratios in pediatric trauma patients, prospective studies are necessary to determine the optimum blood product ratios to minimize mortality in this population.

1Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA.

2Department of Surgery, University of Washington, Seattle, WA.

3Department of Surgery, SUNY Upstate Medical University, Syracuse, NY.

4Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA.

5Center for Pediatric Trauma Research, Nationwide Children’s Hospital, Columbus, OH.

6Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH.

7Shock Trauma and Anesthesia Research Center, University of Maryland, Baltimore, MD.

8Department of Laboratory Medicine, University of Washington, Seattle, WA.

9Department of Pediatrics, University of Washington, Seattle, WA.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Dr. Butler is supported by the Department of Health and Human Services T-32 Pediatric Injury Research Training Program at the Harborview Injury Prevention and Research Center (5T32HD057822-09). Dr. Hess received funding from UptoDate and the U.S. Army. Dr. Rivara received support for article research from the National Institutes of Health. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Elissa K. Butler, MD, Harborview Injury Prevention and Research Center, University of Washington, 325 9th Ave Box 359960, Seattle WA 98104. E-mail: ekbutler@uw.edu

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