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Examining 1:1 Versus 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision
Tejiram S, Sen S, Romanowski KS, Greenhalgh DG, Palmieri TL
Journal of burn care & research : official publication of the American Burn Association. 2020
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Abstract
Blood transfusions following major burn injury are common due to operative losses, blood sampling, and burn physiology. While massive transfusion improves outcomes in adult trauma patients, literature examining its effect in critically ill children is limited. The study purpose was to prospectively compare outcomes of major pediatric burns receiving a 1:1 vs 4:1 packed red blood cell (PRBC) to fresh frozen plasma (FFP) transfusion strategy during massive burn excision. Children with >20% total body surface area (TBSA) burns were randomized to a 1:1 or 4:1 PRBC/FFP transfusion ratio during burn excision. Parameters examined include patient demographics, burn size, Pediatric Risk of Mortality (PRISM) scores, Pediatric Logistic Organ Dysfunction (PELOD) scores, laboratory values, total blood products transfused, and the presence of blood stream infections or pneumonia. A total of 68 children who met inclusion criteria were randomized into two groups (n=34). Mean age, PRISM scores, estimated blood loss (600 mL (400 - 1175 mL) v 600 mL (300 - 1150 mL), p = 0.68), ventilator days (5 v 9, p = 0.47), and length of stay (57 v 60 days, p = 0.24) had no difference. No differences in frequency of blood stream infection (20 v 18, p = 0.46) or pneumonia events (68 v 116, p = 0.08) were noted. On multivariate analysis, only TBSA burn size, inhalation injury, and PRISM scores (p < 0.05) were significantly associated with infections.
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2.
Randomized comparison of packed red blood cell-to-fresh frozen plasma transfusion ratio of 4: 1 vs 1: 1 during acute massive burn excision
Galganski LA, Greenhalgh DG, Sen S, Palmieri TL
Journal of Burn Care & Research.. 2016;38((3):):194-201
Abstract
This prospective randomized controlled trial compared 1:1 vs 4:1 packed red blood cell with fresh frozen plasma (PRBC/FFP) transfusion strategy on outcomes in children with >20% TBSA burns. Children with >20% TBSA burns were randomized to a 1:1 or 4:1 PRBC/FFP transfusion ratio during burn excision. Parameters measured included demographics, TBSA burn, and Pediatric Risk of Mortality scores. Laboratory values recorded preoperatively, 1 hour, 12 hours, 24 hours, and 1 week postoperatively included prothrombin time, partial thromboplastin time (PTT), international normalized ratio, fibrinogen, protein C, and antithrombin C (AIII). Total number of blood products transfused intraoperatively and during hospitalization was recorded. Forty-five children were enrolled, 22 in the 1:1 and 23 in the 4:1 group. Groups were similar in age, TBSA, and Pediatric Risk of Mortality score. Preoperative fibrinogen, AIII, protein C, hemoglobin, PTT, international normalized ratio, and platelets were similar. In the first two excisions, the 1:1 group received significantly more FFP per patient. Volume of PRBC and overall product transfused did not differ between groups. At 1 hour postoperatively, prothrombin time and PTT were lower and protein C and AIII were higher in the 1:1 group. The 4:1 group was more significantly acidotic 1 hour postexcision. A 1:1 PRBC/FFP transfusion strategy, compared with a 4:1 strategy, decreased postoperative markers of coagulopathy and acidosis immediately after surgery. The strategy did not change the total volume of blood product transfused. This interim analysis was not powered to detect differences in wound healing and length of stay. ES 1559-0488 IL 1559-047X
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Evaluation of the "early" use of albumin in children with extensive burns: a randomized controlled trial
Muller Dittrich MH, Brunow de Carvalho W, Lopes Lavado E
Pediatric Critical Care Medicine : a Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2016;17((6):):e280-6
Abstract
OBJECTIVE To compare early versus delayed albumin resuscitation in children with burns in terms of clinical outcome and response. DESIGN Randomized controlled trial. SETTING Burn center at a tertiary care teaching hospital. PATIENTS Forty-six children aged 1-12 years with burns greater than 15-45% total body surface area admitted within 12 hours of burn injury. INTERVENTIONS Fluid resuscitation was based on the Parkland formula (3 mL/kg/% total body surface area), adjusted according to urine output. Patients received 5% albumin solution between 8 and 12 hours post burn in the intervention group (n = 23) and 24 hours post burn in the control group (n = 23). Both groups were assessed for reduction in crystalloid fluid infusion during resuscitation, development of fluid creep, and length of hospital stay. MEASUREMENTS AND MAIN RESULTS There was no difference between groups regarding age, weight, sex, % total body surface area, cause of burn, or severity scores. The median crystalloid fluid volume required during the first 3 days post burn was lower in the intervention than in the control group (2.04 vs 3.05 mL/kg/% total body surface area; p = 0.025 on day 1; 1.2 vs 1.71 mL/kg/% total body surface area; p = 0.002 on day 2; and 0.82 vs 1.3 mL/kg/% total body surface area; p = 0.002 on day 3). The median urine output showed no difference between intervention and control groups (2.1 vs 2.0 mL/kg/hr; p = 0.152 on day 1; 2.58 vs 2.54 mL/kg/hr; p = 0.482 on day 2; and 2.9 vs 3.0 mL/kg/hr; p = 0.093 on day 3). Fluid creep was observed in 13 controls (56.5%) and in one patient (4.3%) in the intervention group. The median length of hospital stay was 18 days (range, 15-21 d) for controls and 14 days (range, 10-17 d) in the intervention group (p = 0.004). CONCLUSIONS Early albumin infusion in children with burns greater than 15-45% total body surface area reduced the need for crystalloid fluid infusion during resuscitation. Significantly fewer cases of fluid creep and shorter hospital stay were also observed in this group of patients.
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Maintenance of serum albumin levels in pediatric burn patients: a prospective, randomized trial
Greenhalgh DG, Housinger TA, Kagan RJ, Rieman M, James L, Novak S, Farmer L, Warden GD
Journal of Trauma-Injury Infection & Critical Care. 1995;39((1):):67-73; discussion 73-4.
Abstract
A prospective, randomized trial was performed to determine whether maintaining serum albumin levels in burned pediatric patients had any effect on morbidity and mortality. Patients < 19 years of age with burns > 20% total body surface area were randomized to receive supplemental albumin to maintain levels 2.5 to 3.5 g/dL ("High Albumin") or were given albumin only if levels dropped < 1.5 g/dL ("Low Albumin") after completing burn shock resuscitation. The 36 patients in the Low Albumin group were well matched for age, burn size, depth of injury, and inhalation injury when compared with the High Albumin group (34 patients). As expected, serum albumin levels were significantly lower in the Low Albumin group when compared with the High Albumin group. No differences between groups were noted for resuscitation needs, maintenance fluid requirements, urine output, tube feedings received, days of antibiotic treatment, or ventilatory requirements. No differences in hematology, electrolytes, or nutritional laboratories were found. Finally, length of stay, complication rate, and mortality were not affected by albumin treatment. Albumin supplementation to maintain normal serum levels does not seem to be warranted in previously healthy children who suffer severe burns and who receive adequate nutrition.
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5.
Clinical evaluation of the administration of large volumes of plasma in the treatment of severely burned children
Bocanegra MC, Bazan AA, Velarde NZ, Carpio MT
Surgery. 1978;83((5):):558-563.