High-Ratio Blood Transfusions May Lower Risk of Fatal Bleeds in Children

A study presented at American Academy of Pediatrics annual meeting suggests that using a high ratio of fresh-frozen plasma to packed red blood cells (RBCs) was associated with a significantly lower risk of fatal hemorrhage in pediatric trauma patients receiving massive transfusions. Improved survival with high-ratio transfusion has been shown in adults in military and civilian studies but had not yet been shown in pediatric trauma patients.

The small retrospective study, presented by Ruth Hwu, MD, of Washington University in St. Louis, MO, suggests that the survival benefit appears greater in patients without severe traumatic brain injury.

The researchers performed a retrospective chart review of pediatric trauma patients treated from 2006 through 2012 at a level I pediatric trauma center. Patients were younger than 18 years of age and received massive transfusions (≥40 mL/kg packed RBCs or ≥80 mL/kg total blood product) during the first 24 hours post-injury. High-ratio transfusion was defined as plasma-RBC ratio ≥1:2. Low-ratio transfusion was anything less than 1:2.

The study included 38 patients, 24 who received high-ratio transfusions and 14 who received low-ratio transfusions. Patients who died within one hour of arrival at the trauma center, arrived more than 24 hours after injury or who had injuries related to burns, hanging or drowning were excluded.

Patients in the high-ratio group required significantly less intravenous fluid during the first 24 hours. The 24-hour mortality did not differ significantly but was lower in the high-ratio group. Overall, mortality did not differ significantly [11/24 (45.8%) in the high-ratio group, versus 9/14 (64.3%) in the low-ratio group (P=0.27).

The cause of death was traumatic brain injury in 10 of 11 cases in the high-ratio group; no patients died of hemorrhage. In the low-ratio group, five of nine deaths were from traumatic brain injury and three from hemorrhage—a difference that did achieve statistical significance in favor of the high-ratio group.

When patients with no traumatic brain injury were excluded from analysis, there was a significant survival difference in favor of high-ratio transfusion (P = 0.0492).