A higher plasma to red cell ratio is associated with lower 24-hour mortality in injured children receiving massive transfusion

Abstract

Background: Higher fresh frozen plasma (FFP) and platelet to packed red blood cell (PRBC) ratios are associated with decreased mortality in injured adults. We sought to determine if higher FFP:PRBC and platelet:PRBC ratios are associated with lower 24-hour mortality in bleeding pediatric trauma patients. Methods: This was a retrospective cohort study using the Pediatric Trauma Quality Improvement Program Database from 2014 to 2016. Injured children (≤14 years) who received massive transfusion (≥40 mL/kg total blood products in 24 hours) were included. Multivariable Poisson regression was used to determine the association between ratios of FFP:PRBC and platelet:PRBC and 24-hour mortality. Results: Of 123,836 patients, 590 underwent massive transfusion, of which 583 met inclusion criteria. Of included patients, 60% were male and the median age was 5 (IQR 2 to 10) years. Cohort 24-hour mortality was 19.7% (95% CI: 16.6 to 23.2%). The high (≥1:1) and medium (≥1:2 and <1:1) FFP:PRBC ratio groups had a lower risk of death at 24 hours (high: aRR 0.49, 95% CI: 0.27 to 0.87; medium: aRR 0.60, 95% CI: 0.39 to 0.92) compared to the low ratio group (<1:2). There was no association between platelet:PRBC ratio and mortality (aRR: 0.94, 95% CI 0.51 to 1.71). Conclusions: Severely injured children with hemorrhage likely benefit from higher FFP:PRBC ratios. While this study is the largest study evaluating blood product ratios in pediatric trauma patients, larger prospective studies are necessary to further evaluate the optimum blood product ratios to minimize mortality in this population.