Diluting the benefits of hemostatic resuscitation

A multi-institutional analysis

Juan Carlos Duchesne, Jiselle Heaney, Chrissy Guidry, Norman McSwain, Peter Meade, Mitchell Cohen, Martin Schreiber, Kenji Inaba, Dimitra Skiada, Demetrius Demetriades, John Holcomb, Charles Wade, Bryan Cotton

    Research output: Contribution to journalArticle

    44 Citations (Scopus)

    Abstract

    BACKGROUND: Although minimization of crystalloids is a widely adopted practice in the resuscitation of patients with severe hemorrhage, its direct impact on high-ratio resuscitation (HRR) outcomes has not been analyzed.We hypothesize that HRR patients will have worse outcomes from crystalloid use. METHODS: This was a 4-year retrospective multi-institutional analysis (MIA) of patients who received massive transfusion protocol (MTP) managed with damage-control laparotomy. Ratios of fresh frozen plasmaYpacked red blood cell (PRBC) were calculated and divided in two groups: HRR (1-1:2) and low-ratio resuscitation (LRR G 1:2). Major outcome of interest was to analyze the direct impact of 24-hour crystalloid volume on HRR MTP patients who received 10 or more units of PRBC. Statistical analysis included analysis of variance, Fisher's exact, Kaplan-Meier (KM) survival curves, and multiple logistic regression. RESULTS: Total of five Level I trauma centers participated with 451 patients who received MTP with 10 or more units of PRBC (fresh frozen plasma/PRBC ratios, n = 365 (80.9%) HRR vs. n = 86 (19.0%) LRR. Overall 24-hour KM survival for the HRR versus LRR was 85.2% versus 68.6% ( p = 0.0004). The volume of crystalloids on KM survival curve in HRR MTP patients was not significant for mortality ( p = 0.52). Morbidity odds ratios (95% confidence interval) for complications were not significant for HRR but were for crystalloids: bacteremia, 1.05 (1.0-1.1); adult respiratory distress syndrome, 1.13 (1.0-1.2), and acute renal failure, 1.05 (1.0-1.1). CONCLUSION: Our MIA results support previous studies with decreased mortality in HRR group when compared with LRR. This is the first MIA to demonstrate increased morbidity from crystalloid use in HRR.Within all MTPs with 10 or more units of PRBC, HRR was not a predictor of morbidity, but crystalloid volume was. Caution in overzealous use of crystalloid during HRR is warranted.

    Original languageEnglish (US)
    Pages (from-to)76-82
    Number of pages7
    JournalJournal of Trauma and Acute Care Surgery
    Volume75
    Issue number1
    DOIs
    StatePublished - Jul 2013

    Fingerprint

    Hemostatics
    Resuscitation
    Erythrocytes
    Kaplan-Meier Estimate
    Morbidity
    Mortality
    crystalloid solutions
    Trauma Centers
    Adult Respiratory Distress Syndrome
    Bacteremia
    Acute Kidney Injury
    Laparotomy
    Analysis of Variance
    Logistic Models
    Odds Ratio

    Keywords

    • Crystalloids
    • Damage control resuscitation
    • Hemostatic resuscitation
    • Multi-institutional analysis
    • Outcomes

    ASJC Scopus subject areas

    • Critical Care and Intensive Care Medicine
    • Surgery

    Cite this

    Duchesne, J. C., Heaney, J., Guidry, C., McSwain, N., Meade, P., Cohen, M., ... Cotton, B. (2013). Diluting the benefits of hemostatic resuscitation: A multi-institutional analysis. Journal of Trauma and Acute Care Surgery, 75(1), 76-82. https://doi.org/10.1097/TA.0b013e3182987df3

    Diluting the benefits of hemostatic resuscitation : A multi-institutional analysis. / Duchesne, Juan Carlos; Heaney, Jiselle; Guidry, Chrissy; McSwain, Norman; Meade, Peter; Cohen, Mitchell; Schreiber, Martin; Inaba, Kenji; Skiada, Dimitra; Demetriades, Demetrius; Holcomb, John; Wade, Charles; Cotton, Bryan.

    In: Journal of Trauma and Acute Care Surgery, Vol. 75, No. 1, 07.2013, p. 76-82.

    Research output: Contribution to journalArticle

    Duchesne, JC, Heaney, J, Guidry, C, McSwain, N, Meade, P, Cohen, M, Schreiber, M, Inaba, K, Skiada, D, Demetriades, D, Holcomb, J, Wade, C & Cotton, B 2013, 'Diluting the benefits of hemostatic resuscitation: A multi-institutional analysis', Journal of Trauma and Acute Care Surgery, vol. 75, no. 1, pp. 76-82. https://doi.org/10.1097/TA.0b013e3182987df3
    Duchesne, Juan Carlos ; Heaney, Jiselle ; Guidry, Chrissy ; McSwain, Norman ; Meade, Peter ; Cohen, Mitchell ; Schreiber, Martin ; Inaba, Kenji ; Skiada, Dimitra ; Demetriades, Demetrius ; Holcomb, John ; Wade, Charles ; Cotton, Bryan. / Diluting the benefits of hemostatic resuscitation : A multi-institutional analysis. In: Journal of Trauma and Acute Care Surgery. 2013 ; Vol. 75, No. 1. pp. 76-82.
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    abstract = "BACKGROUND: Although minimization of crystalloids is a widely adopted practice in the resuscitation of patients with severe hemorrhage, its direct impact on high-ratio resuscitation (HRR) outcomes has not been analyzed.We hypothesize that HRR patients will have worse outcomes from crystalloid use. METHODS: This was a 4-year retrospective multi-institutional analysis (MIA) of patients who received massive transfusion protocol (MTP) managed with damage-control laparotomy. Ratios of fresh frozen plasmaYpacked red blood cell (PRBC) were calculated and divided in two groups: HRR (1-1:2) and low-ratio resuscitation (LRR G 1:2). Major outcome of interest was to analyze the direct impact of 24-hour crystalloid volume on HRR MTP patients who received 10 or more units of PRBC. Statistical analysis included analysis of variance, Fisher's exact, Kaplan-Meier (KM) survival curves, and multiple logistic regression. RESULTS: Total of five Level I trauma centers participated with 451 patients who received MTP with 10 or more units of PRBC (fresh frozen plasma/PRBC ratios, n = 365 (80.9{\%}) HRR vs. n = 86 (19.0{\%}) LRR. Overall 24-hour KM survival for the HRR versus LRR was 85.2{\%} versus 68.6{\%} ( p = 0.0004). The volume of crystalloids on KM survival curve in HRR MTP patients was not significant for mortality ( p = 0.52). Morbidity odds ratios (95{\%} confidence interval) for complications were not significant for HRR but were for crystalloids: bacteremia, 1.05 (1.0-1.1); adult respiratory distress syndrome, 1.13 (1.0-1.2), and acute renal failure, 1.05 (1.0-1.1). CONCLUSION: Our MIA results support previous studies with decreased mortality in HRR group when compared with LRR. This is the first MIA to demonstrate increased morbidity from crystalloid use in HRR.Within all MTPs with 10 or more units of PRBC, HRR was not a predictor of morbidity, but crystalloid volume was. Caution in overzealous use of crystalloid during HRR is warranted.",
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    AU - Duchesne, Juan Carlos

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    AU - McSwain, Norman

    AU - Meade, Peter

    AU - Cohen, Mitchell

    AU - Schreiber, Martin

    AU - Inaba, Kenji

    AU - Skiada, Dimitra

    AU - Demetriades, Demetrius

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    AU - Wade, Charles

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    N2 - BACKGROUND: Although minimization of crystalloids is a widely adopted practice in the resuscitation of patients with severe hemorrhage, its direct impact on high-ratio resuscitation (HRR) outcomes has not been analyzed.We hypothesize that HRR patients will have worse outcomes from crystalloid use. METHODS: This was a 4-year retrospective multi-institutional analysis (MIA) of patients who received massive transfusion protocol (MTP) managed with damage-control laparotomy. Ratios of fresh frozen plasmaYpacked red blood cell (PRBC) were calculated and divided in two groups: HRR (1-1:2) and low-ratio resuscitation (LRR G 1:2). Major outcome of interest was to analyze the direct impact of 24-hour crystalloid volume on HRR MTP patients who received 10 or more units of PRBC. Statistical analysis included analysis of variance, Fisher's exact, Kaplan-Meier (KM) survival curves, and multiple logistic regression. RESULTS: Total of five Level I trauma centers participated with 451 patients who received MTP with 10 or more units of PRBC (fresh frozen plasma/PRBC ratios, n = 365 (80.9%) HRR vs. n = 86 (19.0%) LRR. Overall 24-hour KM survival for the HRR versus LRR was 85.2% versus 68.6% ( p = 0.0004). The volume of crystalloids on KM survival curve in HRR MTP patients was not significant for mortality ( p = 0.52). Morbidity odds ratios (95% confidence interval) for complications were not significant for HRR but were for crystalloids: bacteremia, 1.05 (1.0-1.1); adult respiratory distress syndrome, 1.13 (1.0-1.2), and acute renal failure, 1.05 (1.0-1.1). CONCLUSION: Our MIA results support previous studies with decreased mortality in HRR group when compared with LRR. This is the first MIA to demonstrate increased morbidity from crystalloid use in HRR.Within all MTPs with 10 or more units of PRBC, HRR was not a predictor of morbidity, but crystalloid volume was. Caution in overzealous use of crystalloid during HRR is warranted.

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    KW - Hemostatic resuscitation

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