While the incidence of paediatric trauma requiring massive transfusion is lower than the incidence in adults, little is known regarding the optimal transfusion strategy in the paediatric population. Although optimal ratios for red blood cell, plasma and platelet transfusion have been extensively discussed in the literature, only a limited number of studies can be found for the paediatric trauma population.

In their retrospective analysis of a large American database (Pediatric Trauma Quality Improvement Program Database), Butler et al. evaluated a large cohort of civilian paediatric trauma patients requiring massive transfusion. The primary objective of their study was to determine whether there is an association between higher FFP:PRBC and PLT:PRBC ratios and lower mortality in paediatric trauma patients.

Of 123 836 patients, 590 underwent massive transfusion, of which 583 met inclusion criteria. The overall mortality rate was 19.7% (95% CI, 16.6–23.2) at 24 hours. The adjusted relative risk of 24-hour mortality was 0.49 (95% CI, 0.27–0.87; P = 0.02) and 0.60 (95% CI, 0.39–0.92; P = 0.02) for the high (≥1:1) and medium (≥1:2 and <1:1) FFP:PRBC ratio groups, respectively, compared with the low ratio group (<1:2). PLT:PRBC ratio was not associated with mortality.

The results of this study are important as few analyses of the paediatric trauma population have been published to date. Although the authors suggest a benefit of higher FFP:PRBC ratios, further well-designed and prospective studies are needed to objectively compare different transfusion strategies. The limitations of such retrospective analyses of large databases have been extensively debated in the adult literature, and the results of this paediatric study should be interpreted with caution.

Considering the increasing number of paediatric trauma, there is certainly a need for the development of standardised transfusion protocols and guidelines for the paediatric population.

– David Faraoni