Faculty Collaboration Database

Staying on target: Maintaining a balanced resuscitation during damage-control resuscitation improves survival. J Trauma Acute Care Surg 2021 Nov 01;91(5):841-848

Date

04/27/2021

Pubmed ID

33901052

Pubmed Central ID

PMC8547746

DOI

10.1097/TA.0000000000003245

Scopus ID

2-s2.0-85116769703 (requires institutional sign-in at Scopus site)   11 Citations

Abstract

BACKGROUND: Damage-control resuscitation (DCR) improves survival in severely bleeding patients. However, deviating from balanced transfusion ratios during a resuscitation may limit this benefit. We hypothesized that maintaining a balanced resuscitation during DCR is independently associated with improved survival.

METHODS: This was a secondary analysis of the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. Patients receiving >3 U of packed red blood cells (PRBCs) during any 1-hour period over the first 6 hours and surviving beyond 30 minutes were included. Linear regression assessed the effect of percent time in a high-ratio range on 24-hour survival. We identified an optimal ratio and percent of time above the target ratio threshold by Youden's index. We compared patients with a 6-hour ratio above the target and above the percent time threshold (on-target) with all others (off-target). Kaplan-Meier analysis assessed the combined effect of blood product ratio and percent time over the target ratio on 24-hour and 30-day survival. Multivariable logistic regression identified factors independently associated with 24-hour and 30-day survival.

RESULTS: Of 1,245 PROMMTT patients, 524 met the inclusion criteria. Optimal targets were plasma/PRBC and platelet/PRBC of 0.75 (3:4) and ≥40% time spent over this threshold. For plasma/PRBC, on-target (n = 213) versus off-target (n = 311) patients were younger (median, 31 years; interquartile range, [22-50] vs. 40 [25-54]; p = 0.002) with similar injury burdens and presenting physiology. Similar patterns were observed for platelet/PRBC on-target (n = 116) and off-target (n = 408) patients. After adjusting for differences, on-target plasma/PRBC patients had significantly improved 24-hour (odds ratio, 2.25; 95% confidence interval, 1.20-4.23) and 30-day (odds ratio, 1.97; 95% confidence interval, 1.14-3.41) survival, while on-target platelet/PRBC patients did not.

CONCLUSION: Maintaining a high ratio of plasma/PRBC during DCR is independently associated with improved survival. Performance improvement efforts and prospective studies should capture time spent in a high-ratio range.

LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level II; Therapeutic, level IV.

Author List

Hynes AM, Geng Z, Schmulevich D, Fox EE, Meador CL, Scantling DR, Holena DN, Abella BS, Young AJ, Holland S, Cacchione PZ, Wade CE, Cannon JW, PROMMTT Study Group

Author

Daniel N. Holena MD Professor in the Surgery department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Adult
Blood Transfusion
Female
Hemorrhage
Hospital Mortality
Humans
Injury Severity Score
Kaplan-Meier Estimate
Male
Middle Aged
Practice Guidelines as Topic
Prospective Studies
Resuscitation
Retrospective Studies
Treatment Outcome
Wounds, Nonpenetrating
Young Adult