Prospective comparison of packed red blood cell-to-fresh frozen plasma transfusion ratio of 4: 1 versus 1: 1 during acute massive burn excision

J Trauma Acute Care Surg. 2013 Jan;74(1):76-83. doi: 10.1097/TA.0b013e31827891b7.


Background: Acute burn excision results in at least 2% blood volume loss per percent excised; hence, massive blood loss (>50% total blood volume) occurs during major burn excisions. The purpose of this pilot study was to assess safety and prospectively compare the impact of a 4:1 versus a 1:1 packed red blood cell-fresh frozen plasma (PRBC/FFP) transfusion strategy on outcomes in children with burns greater than 20% total body surface area (TBSA).

Methods: Children with greater than 20% TBSA burn were randomized to a 1:1 or 4:1 PRBC/FFP ratio during burn excision. Parameters measured on admission included demographics, burn size, and Pediatric Risk of Mortality scores. Laboratory values that were measured preoperatively, 1 hour, 12 hours, 24 hours, and 1 week included prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), fibrinogen, protein C, and antithrombin C (AIII). Total number of blood products transfused during operative interventions and during hospitalization were recorded.

Results: Groups were similar in age, weight, TBSA, and Pediatric Risk of Mortality scores at admission. Preoperative fibrinogen, antithrombins III (AIII), protein C, hemoglobin, PT/PTT, INR, and platelets were similar between groups. The 1:1 group received more FFP (43.8 ± 0.03 U in 1:1 group vs. 15.7 ± 0.07 in the 4:1 group) and less PRBC (40.7 ± 0.02 U in 1:1 group vs. 73.1 ± 0.02 U in 4:1 group) than the 4:1 group. Approximately 50% blood volume was replaced with PRBC intraopaeratively. There was no difference in PT/PTT, INR, hemoglobin, or platelets between groups. Protein C and AIII were higher in the 1:1 group. Cost of FFP and PRBC were lower in the 1:1 group.

Conclusion: A 1:1 PRBC/FFP transfusion strategy increased FFP use, decreased overall PRBC use, and resulted in higher AIII and protein C postoperatively without a difference in INR or PT/PTT. This may represent compensatory changes in the 4:1 group in response to intraoperative blood loss.

Level of evidence: Therapeutic, level II.

Publication types

  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Antithrombin III / analysis
  • Blood Coagulation Disorders / etiology
  • Blood Loss, Surgical
  • Blood Transfusion / methods
  • Burns / pathology
  • Burns / surgery*
  • Child
  • Debridement
  • Erythrocyte Transfusion*
  • Female
  • Humans
  • Male
  • Plasma*
  • Protein C / analysis
  • Skin Transplantation


  • Protein C
  • Antithrombin III