Staying on target: Maintaining a balanced resuscitation during damage-control resuscitation improves survival. Issue 5 (26th November 2021)

• Record Type: Journal Article
• Authors: Hynes, Allyson M.; Geng, Zhi; Schmulevich, Daniela; Fox, Erin E.; Meador, Christopher L.; Scantling, Dane R.; Holena, Daniel N.; Abella, Benjamin S.; Young, Andrew J.; Holland, Sara; Cacchione, Pamela Z.; Wade, Charles E.; Cannon, Jeremy W.
• Is Part Of: Journal of trauma and acute care surgery. Volume 91:Issue 5(2021)
• Page Start: 841
• Page End: 848
• Publication Date: 2021-11-26
• Subjects: Coagulopathy -- PROMMTT -- massive transfusion -- shock -- hemorrhagic -- resuscitation; Surgical intensive care -- Periodicals; Surgical emergencies -- Periodicals; Wounds and injuries -- Surgery -- Periodicals; 617.026
• DOI: 10.1097/TA.0000000000003245
• Languages: English
• ISSNs: 2163-0755

Abstract

Abstract : Supplemental digital content is available in the text. 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.