Prevalence and outcomes of high versus low ratio plasma to red blood cell resuscitation in a multi-institutional cohort of severely injured children

Steven C Mehl; Adam M Vogel; Amy E Glasgow; Suzanne Moody; Meera Kotagal; Regan F Williams; Mark L Kayton; Emily C Alberto; Randall S Burd; Thomas J Schroeppel; Joanne E Baerg; Amanda Munoz; William B Rothstein; Laura A Boomer; Eric M Campion; Caitlin Robinson; Rachel M Nygaard; Chad J Richardson; Denise I Garcia; Christian J Streck; Michaela Gaffley; John K Petty; Cynthia Greenwell; Samir Pandya; Alicia M Waters; Robert T Russell; Brian K Yorkgitis; Jennifer Mull; Jeffrey Pence; Matthew T Santore; Taleen A MacArthur; Denise B Klinkner; Shawn D Safford; Tanya Trevilian; Megan Cunningham; Christa Black; Jessica Rea; Ryan G Spurrier; Aaron R Jensen; Bethany J Farr; David P Mooney; Bavana Ketha; Melvin S Dassinger 3rd; Anna Goldenberg-Sandau; Janika San Roman; Todd M Jenkins; Richard A Falcone Jr; Stephanie Polites

doi:10.1097/TA.0000000000004301

Prevalence and outcomes of high versus low ratio plasma to red blood cell resuscitation in a multi-institutional cohort of severely injured children

J Trauma Acute Care Surg. 2024 Sep 1;97(3):452-459. doi: 10.1097/TA.0000000000004301. Epub 2024 Mar 18.

Authors

Steven C Mehl¹, Adam M Vogel, Amy E Glasgow, Suzanne Moody, Meera Kotagal, Regan F Williams, Mark L Kayton, Emily C Alberto, Randall S Burd, Thomas J Schroeppel, Joanne E Baerg, Amanda Munoz, William B Rothstein, Laura A Boomer, Eric M Campion, Caitlin Robinson, Rachel M Nygaard, Chad J Richardson, Denise I Garcia, Christian J Streck, Michaela Gaffley, John K Petty, Cynthia Greenwell, Samir Pandya, Alicia M Waters, Robert T Russell, Brian K Yorkgitis, Jennifer Mull, Jeffrey Pence, Matthew T Santore, Taleen A MacArthur, Denise B Klinkner, Shawn D Safford, Tanya Trevilian, Megan Cunningham, Christa Black, Jessica Rea, Ryan G Spurrier, Aaron R Jensen, Bethany J Farr, David P Mooney, Bavana Ketha, Melvin S Dassinger 3rd, Anna Goldenberg-Sandau, Janika San Roman, Todd M Jenkins, Richard A Falcone Jr, Stephanie Polites

Affiliation

¹ From the Department of Surgery (S.C.M., A.M.V., M.C.), Baylor College of Medicine, Texas Children's Hospital, Houston, Texas; Department of Surgery (A.E.G., T.A.MA., D.B.K., S.F.P.), Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota; Department of Surgery (A.E.G., T.A.MA., D.B.K., T.M.J., R.A.F., S.F.P.), Mayo Clinic, Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota; Department of Surgery (S.M., M.K.), Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Surgery (R.F.W.), Le Bonheur Children's Hospital, Memphis, Tennessee; Department of Surgery (M.L.K.), K. Hovnanian Children's Hospital at Jersey Shore University Medical Center, Hackensack-Meridian Health Network, Neptune, New Jersey; Department of Surgery (E.C.A., R.S.B.), Children's National Hospital, Washington, DC; Department of Surgery (T.J.S.), UCHealth Memorial Hospital, Colorado Spring, Colorado; Department of Surgery (J.E.B., A.M.), Loma Linda University, Loma Linda, California; Department of Surgery (W.B.R., L.A.B.), Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia; Department of Surgery (E.M.C., C.R.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (R.M.N., C.J.R.), Hennepin Healthcare, Minneapolis, Minnesota; Department of Surgery (D.I.G., C.J.S.), The Medical University of South Carolina, Charleston, South Carolina; Department of Surgery (M.G., J.K.P.), Wake Forest University School of Medicine, Brenner Children's Hospital, Winston-Salem, North Carolina; Department of Surgery (C.G., S.P.), Children's Health Dallas, Dallas, Texas; Department of Surgery (A.M.W., R.T.R.), Children's of Alabama, Birmingham, Alabama; Department of Surgery (B.K.Y., J.M.), College of Medicine, University of Florida-Jacksonville, Jacksonville, Florida; Department of Surgery (J.P.), Dayton Children's Hospital, Dayton, Ohio; Department of Surgery (M.T.S.), Children's Healthcare of Atlanta, Atlanta, Georgia; Department of Surgery (S.D.S.), University of Pittsburgh Medical Center, Harrisburg, Pennsylvania; Department of Surgery (T.T.), Carilion Children's Hospital, Carilion Roanoke Memorial Hospital, Roanoke, Virginia; Department of Surgery (C.B.), ProMedica Toledo and Toledo Children's Hospital, Toledo, Ohio; Department of Surgery (J.R., R.G.S.), Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery (A.R.J.), Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Surgery (B.J.F., D.P.M.), Boston Children's Hospital, Boston, Massachusetts; Department of Surgery (B.K., M.S.D.), Arkansas Children's Hospital, Little Rock, Arkansas; and Department of Surgery (A.G.-S., J.S.R.), Cooper University Hospital, Camden, New Jersey.

PMID: 38497936
DOI: 10.1097/TA.0000000000004301

Abstract

Background: The benefit of targeting high ratio fresh frozen plasma (FFP)/red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP/RBC transfusion and the association with outcomes in children presenting in shock.

Methods: A post hoc analysis of a 24-institution prospective observational study (April 2018 to September 2019) of injured children younger than 18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (≥1:2) ratio FFP/RBC. Nonparametric Kruskal-Wallis and χ 2 were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths.

Results: Of 135 children with median (interquartile range) age 10 (5-14) years and weight 40 (20-64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (low-38%, high-46%, p = 0.34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = 0.01); however, hospital mortality was similar (low-24%, high-20%, p = 0.65) as was the risk of extended ventilator, intensive care unit, and hospital days (all p > 0.05).

Conclusion: Despite increased injury severity, patients who received a high ratio of FFP/RBC had comparable rates of mortality. These data suggest high ratio FFP/RBC resuscitation is not associated with worst outcomes in children who present in shock. Massive transfusion protocol activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers.

Level of evidence: Therapeutic/Care Management; Level III.

Publication types

Observational Study
Multicenter Study

MeSH terms

Adolescent
Blood Component Transfusion / methods
Blood Component Transfusion / statistics & numerical data
Child
Child, Preschool
Erythrocyte Transfusion* / methods
Erythrocyte Transfusion* / statistics & numerical data
Female
Humans
Injury Severity Score
Male
Plasma*
Prevalence
Prospective Studies
Resuscitation* / methods
Treatment Outcome
Wounds and Injuries / complications
Wounds and Injuries / mortality
Wounds and Injuries / therapy