High ratio plasma resuscitation does not improve survival in pediatric trauma patients

Jeremy W Cannon; Michael A Johnson; Robert C Caskey; Matthew A Borgman; Lucas P Neff

doi:10.1097/TA.0000000000001549

High ratio plasma resuscitation does not improve survival in pediatric trauma patients

J Trauma Acute Care Surg. 2017 Aug;83(2):211-217. doi: 10.1097/TA.0000000000001549.

Authors

Jeremy W Cannon¹, Michael A Johnson, Robert C Caskey, Matthew A Borgman, Lucas P Neff

Affiliation

¹ From the Division of Traumatology, Surgical Critical Care & Emergency Surgery (J.W.C.) and the Department of Surgery (R.C.C.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; David Grant Medical Center (J.W.C.), Travis Air Force Base, Fairfield, California; Uniformed Services (J.W.C., M.A.B.), University of the Health Sciences, Bethesda, Maryland; Department of Emergency Medicine (M.A.J.), University of California, Davis, California; Department of Pediatrics (M.A.B.), San Antonio Military Medical Center, Fort Sam Houston, San Antonio, Texas; and Department of Pediatric Surgery (L.P.N.), Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia.

PMID: 28481839
DOI: 10.1097/TA.0000000000001549

Abstract

Background: Damage control resuscitation including balanced resuscitation with high ratios of plasma (PLAS) and platelets (PLT) to packed red blood cells (PRBC) improves survival in adult patients. We sought to evaluate the effect of a high ratio PLAS to PRBC resuscitation strategy in massively transfused pediatric patients with combat injuries.

Methods: The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric trauma patients (<18 years). Burns, drowning, isolated head trauma, and older teens were excluded. Those who received massive transfusion (≥40 mL/kg total blood products in 24 hours) and early deaths who received any blood products were then evaluated. Primary outcomes were mortality at 24 hours and in-hospital. Secondary outcomes included blood product utilization over 24 hours, ventilator-free days, intensive care unit-free days, and hospital length of stay.

Results: The Department of Defense Trauma Registry yielded 4,980 combat-injured pediatric trauma patients, of whom 364 met inclusion criteria. Analysis of PLAS/PRBC ratios across the entire spectrum of possible ratios in these patients demonstrated no clear inflection point for mortality. Using a division between low (LO) and high (HI) ratios of PLAS/PRBC 1:2, there was no difference in all-cause mortality at 24 hours (LO, 9.2% vs. HI, 8.0%; p = 0.75) and hospital discharge (LO, 21.5% vs. HI, 17.1%; p = 0.39). HI ratio patients received less PRBC but more PLAS and PLT and more total blood products. Those in the HI ratio group also had longer hospital length of stay. Regression analysis demonstrated no associated mortality benefit with a HI ratio (hazards ratio, 2.04; 95% confidence interval, 0.48-8.73; p = 0.34).

Conclusion: In combat-injured children undergoing a massive transfusion, a high ratio of PLAS/PRBC was not associated with improved survival. Further prospective studies should be performed to determine the optimal resuscitation strategy in critically injured pediatric patients.

Level of evidence: Therapeutic study, level III.

MeSH terms

Afghan Campaign 2001-*
Cause of Death
Child
Child, Preschool
Emergency Medical Services / methods
Erythrocyte Transfusion / methods*
Female
Hemorrhage / therapy*
Hospital Mortality
Hospitals, Military
Humans
Iraq War, 2003-2011*
Male
Plasma*
Platelet Transfusion / methods*
Proportional Hazards Models
Registries
Resuscitation / methods*
Wounds and Injuries / mortality
Wounds and Injuries / therapy*