Examining 1:1 Versus 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision
Journal of burn care & research : official publication of the American Burn Association. 2020
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.
Restrictive Transfusion Strategy Is More Effective in Massive Burns: Results of the TRIBE Multicenter Prospective Randomized Trial
Military Medicine. 2018
Objectives: Studies suggest that a restrictive transfusion strategy is safe in burns, yet the efficacy of a restrictive transfusion policy in massive burn injury is uncertain. Our objective: compare outcomes between massive burn (≥60% total body surface area (TBSA) burn) and major (20-59% TBSA) burn using a restrictive or a liberal blood transfusion strategy. Methods: Patients with burns ≥20% were block randomized by age and TBSA to a restrictive (transfuse hemoglobin <7 g/dL) or liberal (transfuse hemoglobin <10 g/dL) strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes. Results: Three hundred and forty-five patients received 7,054 units blood, 2,886 in massive and 4,168 in restrictive. Patients were similar in age, TBSA, and inhalation injury. The restrictive group received less blood (45.57 +/- 47.63 vs. 77.16 +/- 55.0, p < 0.03 massive; 11.0 +/- 16.70 vs. 16.78 +/- 17.39, p < 0.001) major). In massive burn, the restrictive group had fewer ventilator days (p < 0.05). Median ICU days and LOS were lower in the restrictive group; wound healing, mortality, and infection did not differ. No significant outcome differences occurred in the major (20-59%) group (p > 0.05). Conclusions: A restrictive transfusion strategy may be beneficial in massive burns in reducing ventilator days, ICU days and blood utilization, but does not decrease infection, mortality, hospital LOS or wound healing.
The Effects of Storage Age of Blood in Massively Transfused Burn Patients: A Secondary Analysis of the Randomized Transfusion Requirement in Burn Care Evaluation Study
Critical Care Medicine. 2018;46((12):):e1097-e1104.
OBJECTIVES Major trials examining storage age of blood transfused to critically ill patients administered relatively few blood transfusions. We sought to determine if the storage age of blood affects outcomes when very large amounts of blood are transfused. DESIGN A secondary analysis of the multicenter randomized Transfusion Requirement in Burn Care Evaluation study which compared restrictive and liberal transfusion strategies. SETTING Eighteen tertiary-care burn centers. PATIENTS Transfusion Requirement in Burn Care Evaluation evaluated 345 adults with burns greater than or equal to 20% of the body surface area. We included only the 303 patients that received blood transfusions. INTERVENTIONS The storage ages of all transfused red cell units were collected during Transfusion Requirement in Burn Care Evaluation. A priori measures of storage age were the the mean storage age of all transfused blood and the proportion of all transfused blood considered very old (stored ≥ 35 d). MEASUREMENTS AND MAIN RESULTS The primary outcome was the severity of multiple organ dysfunction. Secondary outcomes included time to wound healing, the duration of mechanical ventilation, and in-hospital mortality. There were 6,786 red cell transfusions with a mean (+/- SD) storage age of 25.6 +/- 10.2 days. Participants received a mean of 23.4 +/- 31.2 blood transfusions (range, 1-219) and a mean of 5.3 +/- 10.7 units of very old blood. Neither mean storage age nor proportion of very old blood had any influence on multiple organ dysfunction severity, time to wound healing, or mortality. Duration of ventilation was significantly predicted by both mean blood storage age and the proportion of very old blood, but this was of questionable clinical relevance given extreme variability in duration of ventilation (adjusted r ≤ 0.01). CONCLUSIONS Despite massive blood transfusion, including very old blood, the duration of red cell storage did not influence outcome in burn patients. Provision of the oldest blood first by Blood Banks is rational, even for massive transfusion.
Transfusion Requirement in Burn Care Evaluation (TRIBE): a multicenter randomized prospective trial of blood transfusion in major burn injury
Annals of Surgery. 2017;266((4):):595-602
OBJECTIVE Our objective was to compare outcomes of a restrictive to a liberal red cell transfusion strategy in 20% or more total body surface area (TBSA) burn patients. We hypothesized that the restrictive group would have less blood stream infection (BSI), organ dysfunction, and mortality. BACKGROUND Patients with major burns have major (>1 blood volume) transfusion requirements. Studies suggest that a restrictive blood transfusion strategy is equivalent to a liberal strategy. However, major burn injury is precluded from these studies. The optimal transfusion strategy in major burn injury is thus needed but remains unknown. METHODS This prospective randomized multicenter trial block randomized patients to a restrictive (hemoglobin 7-8 g/dL) or liberal (hemoglobin 10-11 g/dL) transfusion strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes. RESULTS Eighteen burn centers enrolled 345 patients with 20% or more TBSA burn similar in age, TBSA burn, and inhalation injury. A total of 7054 units blood were transfused. The restrictive group received fewer blood transfusions: mean 20.3 +/- 32.7 units, median = 8 (interquartile range: 3, 24) versus mean 31.8 +/- 44.3 units, median = 16 (interquartile range: 7, 40) in the liberal group (P < 0.0001, Wilcoxon rank sum). BSI incidence, organ dysfunction, ventilator days, and time to wound healing (P > 0.05) were similar. In addition, there was no 30-day mortality difference: 9.5% restrictive versus 8.5% liberal (P = 0.892, chi test). CONCLUSIONS A restrictive transfusion strategy halved blood product utilization. Although the restrictive strategy did not decrease BSI, mortality, or organ dysfunction in major burn injury, these outcomes were no worse than the liberal strategy (Clinicaltrials.gov identifier NCT01079247).
Randomized comparison of packed red blood cell-to-fresh frozen plasma transfusion ratio of 4: 1 vs 1: 1 during acute massive burn excision
Journal of Burn Care & Research.. 2016;38((3):):194-201
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
Prospective comparison of packed red blood cell-to-fresh frozen plasma transfusion ratio of 4: 1 versus 1: 1 during acute massive burn excision
The Journal of Trauma and Acute Care Surgery. 2013;74((1):):76-83.
BACKGROUND Acute burn excision results in at least 2% blood volume loss per percent excised; hence, massive blood loss (>50% total blood volume) occurs during major burn excisions. The purpose of this pilot study was to assess safety and prospectively compare the impact of a 4:1 versus a 1:1 packed red blood cell-fresh frozen plasma (PRBC/FFP) transfusion strategy on outcomes in children with burns greater than 20% total body surface area (TBSA). METHODS Children with greater than 20% TBSA burn were randomized to a 1:1 or 4:1 PRBC/FFP ratio during burn excision. Parameters measured on admission included demographics, burn size, and Pediatric Risk of Mortality scores. Laboratory values that were measured preoperatively, 1 hour, 12 hours, 24 hours, and 1 week included prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), fibrinogen, protein C, and antithrombin C (AIII). Total number of blood products transfused during operative interventions and during hospitalization were recorded. RESULTS Groups were similar in age, weight, TBSA, and Pediatric Risk of Mortality scores at admission. Preoperative fibrinogen, antithrombins III (AIII), protein C, hemoglobin, PT/PTT, INR, and platelets were similar between groups. The 1:1 group received more FFP (43.8 +/- 0.03 U in 1:1 group vs. 15.7 +/- 0.07 in the 4:1 group) and less PRBC (40.7 +/- 0.02 U in 1:1 group vs. 73.1 +/- 0.02 U in 4:1 group) than the 4:1 group. Approximately 50% blood volume was replaced with PRBC intraopaeratively. There was no difference in PT/PTT, INR, hemoglobin, or platelets between groups. Protein C and AIII were higher in the 1:1 group. Cost of FFP and PRBC were lower in the 1:1 group. CONCLUSION A 1:1 PRBC/FFP transfusion strategy increased FFP use, decreased overall PRBC use, and resulted in higher AIII and protein C postoperatively without a difference in INR or PT/PTT. This may represent compensatory changes in the 4:1 group in response to intraoperative blood loss. LEVEL OF EVIDENCE Therapeutic, level II.