Impact of Balanced Versus Unbalanced Blood Product Ratios on Mortality
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Casey S.
Karageorgos S.
Davis, T.
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2025
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Introduction Haemorrhage is the leading cause of early mortality in paediatric trauma patients (PTP). Many paediatric massive transfusion (MT) protocols advocate for a balanced transfusion strategy (-1:2 FFP: Platelets: RBC), despite supportive evidence. This review aimed to determine whether balanced transfusion ratios improve 24-hour mortality in PTP undergoing MT (-40 ml/kg total blood products in the first 24 hours). Methods A systematic review and meta-analysis was conducted in accordance with a registered PROSPERO protocol (CRD420250646674) and PRISMA guidelines. MEDLINE, EMBASE, Scopus, and CENTRAL were searched without language or date restriction. Eligible studies included PTP <18 years old who received MT and were grouped according to balanced (-1:2) vs. unbalanced (<1:2) FFP: RBC or Platelet: RBC ratios. Primary outcome was 24-hour mortality. Secondary outcomes included in-hospital mortality, ICU/hospital length of stay, transfusion volumes, adverse events, and cost. Risk of bias and certainty of evidence were assessed using ROBINS-I and GRADE, respectively. Results Six studies with 1664 participants were included. No randomised controlled trials were identified. Meta-analysis of five studies (n=1616) demonstrated a statistically significant reduction in 24-hour mortality associated with balanced FFP: RBC transfusion (OR 0.68; 95% CI 0.52-0.88; p=0.004; I2=0%). No mortality difference was seen with balanced Platelet: RBC ratios (OR 1.02; 95% CI 0.69-1.50; p=0.92). No consistent differences were found in secondary outcomes including ICU/hospital stay, mechanical ventilation or adverse events. Most studies were at critical risk of bias due to survivorship and intervention deviation. Certainty of evidence for all outcomes was low. Conclusion Balanced FFP: RBC transfusion appears safe and may offer an early survival benefit in PTP undergoing MT. This conclusion is limited by low-certainty evidence and high risk of bias in included studies. No benefit was observed with balanced Platelet: RBC ratios. Prospective trials are needed to validate these findings and determine optimal paediatric transfusion strategies..
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Emergency medicine journal : EMJ