Association between the fresh frozen plasma-to-red blood cell ratio and mortality in pediatric severe trauma.

Abstract

The optimal fresh frozen plasma (FFP)-to-red blood cell (RBC) ratio in pediatric severe trauma has not yet been established. We investigated the association between the FFP-to-RBC transfusion ratio and clinical outcomes in pediatric severe trauma, aiming to identify an optimal threshold. This multicenter, retrospective, observational study uses data from the Japan Trauma Data Bank from 2019 to 2023. The study included pediatric patients aged below 18 years with severe trauma (injury severity score >15). Patients were categorized into a high-FFP group (FFP-to-RBC ratio ≥1) and a low-FFP group (ratio of <1). The primary outcome was in-hospital mortality. Inverse probability of treatment weighting based on propensity scores was used to balance patient characteristics. Restricted cubic spline analysis was applied to evaluate the linearity and dose-response effects of the FFP-to-RBC ratio on in-hospital mortality. A weighted mixed-effects logistic regression model accounting for intrahospital clustering was used as a sensitivity analysis. A total of 336 patients were included, with 284 assigned to the high-FFP group. Weighted logistic regression analysis using inverse probability of treatment weighting demonstrated significantly lower in-hospital mortality in the high-FFP group (adjusted odds ratio, 0.47; 95% confidence interval, 0.28-0.78). The restricted cubic spline curve indicated a nonsignificant trend in which in-hospital mortality decreased progressively as the FFP-to-RBC ratio increased. Sensitivity analysis attenuated the association to nonsignificance (adjusted odds ratio, 0.67; 95% confidence interval, 0.29-1.53). A higher FFP-to-RBC ratio was associated with significantly lower in-hospital mortality. However, these findings should be interpreted cautiously, given the retrospective design and sensitivity analysis suggesting potential hospital-level confounding. ( J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). Therapeutic/care management; Level III.