title: Prospective comparison of packed red blood cell-to-fresh frozen plasma transfusion ratio of 4: 1 versus 1: 1 during acute massive burn excision.
abstract: 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.
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Therapeutic, level II.
authors.affiliation: Shriners Hospital for Children Northern California and the University of California Davis Medical Center, Davis, California, USA. tina.palmieri@ucdmc.ucdavis.edu
authors.forename: Tina L
authors.initials: TL
authors.lastname: Palmieri
authors.forename: David G
authors.initials: DG
authors.lastname: Greenhalgh
authors.forename: Soman
authors.initials: S
authors.lastname: Sen
mesh_terms: D000990:Antithrombin III / Q000032:analysis; D001778:Blood Coagulation Disorders / Q000209:etiology; D016063:Blood Loss, Surgical; D001803:Blood Transfusion / Q000379:methods; D002056:Burns / Q000473:pathology / Q000601:surgery*; D002648:Child; D003646:Debridement; D017707:Erythrocyte Transfusion; D005260:Female; D006801:Humans; D008297:Male; D010949:Plasma; D011486:Protein C / Q000032:analysis; D016038:Skin Transplantation
chemical_list: D011486:Protein C; D000990:Antithrombin III