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Prevalence and Outcomes of Low Vs High Ratio Plasma:RBC Resuscitation in a Multi-institutional Cohort of Severely Injured Children
Steven C. Mehl1, *Adam M. Vogel1, *Meera Kotagal2, *Regan F. Williams3, *Mark L. Kayton4, *Emily C. Alberto5, *Thomas J. Schroeppel6, Joanne E. Baerg7, *Laura A. Boomer8, *Eric M. Champion9, *Rachel M. Nygaard10, *Denise I. Garcia11, *Michaela Gaffley12, *Cynthia Greenwell13, Alicia M. Waters14, Brian K. Yorkgitis15, Jeffrey Pence16, *Matthew T Santore17, *Taleen MacArthur18, Shawn D Stafford19, Jessica Rea20, Bethany J. Farr21, Bavana Ketha22, Anna Goldenberg-Sandau23, *Stephanie F. Polites18
1Texas Children's Hospital, Houston, TX; 2Cincinnati Children's Hospital, Cincinnati, OH; 3Le Bonheur Children's Hospital, Memphis, TN; 4Florida and the Palm Beach Children's Hospital, West Palm Beach, FL; 5Children's National, Washington DC, DC; 6Children's Hospital of Colorado, Aurora, CO; 7Loma Linda University, Loma Linda, CA; 8Children's Hospital of Richmond, Richmond, VA; 9Denver Health Medical Center, Denver, CO; 10Hennepin Healthcare, Minneapolis, MN; 11The Medical University of South Carolina, Charleston, SC; 12Brenner Children's Hospital, Winston-Salem, NC; 13Children's Health Dallas, Dallas, TX; 14Children's of Alabama, Birmingham, AL; 15University of Florida-Jacksonville, Jacksonville, FL; 16Dayton Children's Hospital, Dayton, OH; 17Children's Healthcare of Atlanta, Atlanta, GA; 18Mayo Eugenio Litta Children's Hospital, Rochester, MN; 19Carilion Children's Hospital, Roanoke, VA; 20Children's Hospital Los Angeles, Los Angeles, CA; 21Boston Children's Hospital, Boston, MA; 22Arkansas Children's Hospital, Little Rock, AR; 23Cooper University Hospital, Camden, NJ

Background: The benefit of high ratio plasma:red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear with existing studies limited to patients who retrospectively met criteria for massive transfusion.1,2The purpose of this study was to evaluate outcomes associated with receipt of high ratio plasma:RBC transfusion in children presenting in shock.
Methods: A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index and transfusion within 24 hours was performed. Patients were stratified into cohorts of low (<1:2) or high (>1:2) ratio plasma:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risk analysis, accounting for mortality, was used to compare extended (>75thpercentile) ventilator, intensive care, and hospital days.
Findings: Of 135 children with median (IQR) age 10 (5,14) years and 70% blunt injury, 85 (63%) received low ratio and 50 (37%) received high ratio transfusion despite similar activation of institutional massive transfusion protocols (MTP; 38 vs 46%, p=.34). Median total blood product volume was higher for high ratio patients (16 vs 51 mL/kg, p<0.01). Median injury severity score was greater for high ratio patients (25 vs 33, p=.01); however, 24 hour (12 vs 6%, p=.37) and hospital mortality were similar (24 vs 20%, p=.65) as was the risk of extended ventilator, ICU, and hospital days (Table).
Conclusions: Despite increased injury severity, children who received a high ratio plasma:RBC had comparable rates of morbidity and mortality. These data support targeting high ratio plasma:RBC resuscitation for children with signs of hemorrhagic shock at presentation. MTP activation was not associated with receipt of high ratio transfusion, suggesting MTP variability between centers.

Competing risk analysis for low versus high plasma:RBC ratio
OutcomeHazard Ratio (95% CI)p-value
Extended (≥6) ventilator days1.10 (0.76 - 1.59).61
Extended (≥10) intensive care days1.07 (0.74 - 1.54).74
Extended (≥21) hospital days1.14 (0.79 - 1.65).48

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