TY - JOUR
T1 - Diluting the benefits of hemostatic resuscitation
T2 - A multi-institutional analysis
AU - Duchesne, Juan Carlos
AU - Heaney, Jiselle
AU - Guidry, Chrissy
AU - McSwain, Norman
AU - Meade, Peter
AU - Cohen, Mitchell
AU - Schreiber, Martin
AU - Inaba, Kenji
AU - Skiada, Dimitra
AU - Demetriades, Demetrius
AU - Holcomb, John
AU - Wade, Charles
AU - Cotton, Bryan
N1 - Copyright:
Copyright 2014 Elsevier B.V., All rights reserved.
PY - 2013/7
Y1 - 2013/7
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.
AB - 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.
KW - Crystalloids
KW - Damage control resuscitation
KW - Hemostatic resuscitation
KW - Multi-institutional analysis
KW - Outcomes
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U2 - 10.1097/TA.0b013e3182987df3
DO - 10.1097/TA.0b013e3182987df3
M3 - Article
C2 - 23778442
AN - SCOPUS:84880307429
SN - 2163-0755
VL - 75
SP - 76
EP - 82
JO - Journal of Trauma and Acute Care Surgery
JF - Journal of Trauma and Acute Care Surgery
IS - 1
ER -