2 Examining 1:1 Versus 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision

Abstract

Blood transfusions after major burn injury are common due to operative losses, blood sampling, and burn physiology. Burn patients lose an estimated 2% blood volume per percent burn excised, making large burn excisions a major source of blood loss. While a massive transfusion protocol improves outcomes in adult trauma patients, there remains a paucity of literature examining its effect in the critically ill pediatric population. The purpose of this study was to prospectively examine the outcomes of major pediatric burns receiving a 1:1 vs 4:1 red blood cell (RBC) to fresh frozen plasma (FFP) transfusion strategy during massive burn excision. Children with >20% total body surface area (TBSA) 2nd and 3rd degree burns were randomized to a 1:1 or 4:1 RBC/FFP transfusion ratio during burn excision. Parameters measured included patient demographics, burn size, Pediatric Risk of Mortality (PRISM) scores, Pediatric Logistic Organ Dysfunction (PELOD) scores, clinical laboratory values, and total blood products transfused during operative interventions and hospitalization. Blood stream infections (BSI), urinary tract infections (UTI), and pneumonia (PNU), were documented using the burn consensus guidelines for infection. A total of 68 children were randomized into two groups (34 patients in the 1:1 group and 34 patients in the 4:1 group). Mean age (7.4 ± 5.5 v 8.2 ± 5.3 years), TBSA (39% ± 16 v 43% ± 24), and PRISM scores (9.5 ± 6 v 11 ± 6) did not significantly differ between groups. Estimated blood loss also did not significantly differ between groups (453 cc v 450 cc, p = 0.42). No significant differences were noted in ventilatory days (5 v 9, p = 0.47) or overall length of stay (57 v 60, p = 0.24). An equal number of infections were identified in both populations (24 patients each). Although no differences were identified in blood stream infections (20 v 18, p = 0.46), a higher number of pneumonias were documented in the 4:1 group (68 v 116, p = 0.08). On multivariate analysis, significantly higher TBSA (p < 0.001) and PRISM scores (p < 0.05) were identified in the 4:1 group when controlling for infection count. No significant differences were identified in outcomes between a 1:1 and 4:1 massive transfusion strategy as measured by overall ventilator days, length of stay, or rates of infection. These findings would suggest noninferiority to either transfusion practice based on outcomes. Further work will be necessary to fully elucidate these results. This work is an interim analysis of an ongoing study that suggests higher transfusion requirements may occur in higher risk patients such as those with larger TBSA burn sizes or mortality scores.