High-Ratio Blood Could Reduce Fatal Hemorrhage

A new study suggests that a high ratio of fresh-frozen plasma to packed red blood cells (RBCs) could significantly reduce the risk of fatal bleeding in massively transfused pediatric trauma patients.

Researchers at Washington University (St. Louis, MO, USA) conducted a retrospective chart review of pediatric trauma patients treated from 2006 to2012, identifying those who received massive transfusions, defined as more than 40 mL/kg of packed RBCs or more than 80 mL/kg total blood product during the first day after injury. Eligible patients were grouped according to transfusion ratios, with high-ratio transfusion defined as a plasma-RBC ratio over 1:2. Patients who died within one hour of arrival, who arrived more than 24 hours after injury, or who had injuries related to burns, hanging, or drowning were excluded. The primary outcomes were 24-hour mortality and overall mortality; secondary outcome was cause of death.

The results showed that no fatal hemorrhages occurred in 24 patients who received high-ratio transfusions, compared with three fatal hemorrhages in the 14 patients who received low-ratio transfusions. Patients in the high-ratio group also required significantly less fluid during the first 24 hours. The cause of death was traumatic brain injury (TBI) in 10 of 11 cases in the high-ratio group, with no patient dying of hemorrhage. In the low-ratio group, five of nine deaths resulted from TBI and three from hemorrhage. Exclusion of patients with no TBI resulted in a significant survival difference in favor of the high-ratio group. The study was presented at the American Academy of Pediatrics (AAP) meeting, held during October 2013 in Orlando (FL, USA).

“A high ratio of fresh-frozen plasma to packed red blood cells when transfusing massive volumes may be associated with improved survival,” said lead author and stud presenter Ruth Hwu, MD. “The survival benefit appears greater in patients without severe traumatic brain injury. Larger multicenter studies are needed in order to definitely demonstrate improved survival from high-ratio transfusion during massive transfusion in children.”

Acute hemorrhage supersedes all other causes of death in the first six hours after traumatic injury, with as many as 40% of adults and children at trauma centers arriving in coagulopathic states. An improved survival rate with high-ratio transfusions has been demonstrated to addresses this coagulopathy in adult military and civilian studies, but has yet to be shown in pediatric trauma patients.

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