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Diluting the benefits of hemostatic resuscitation: A multi-institutional analysis

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

Journal of Trauma and Acute Care Surgery: July 2013 - Volume 75 - Issue 1 - p 76–82
doi: 10.1097/TA.0b013e3182987df3
EAST 2013 Plenary Papers

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 plasma–packed red blood cell (PRBC) were calculated and divided in two groups: HRR (1–1:2) and low-ratio resuscitation (LRR < 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.

LEVEL OF EVIDENCE Therapeutic study, level IV.

Supplemental digital content is available in the text.

From the Tulane University School of Medicine (J.D., J.He., N.M., P.M.), New Orleans, Louisiana; Akron General (C.G.), Akron, Ohio; University of California (M.C.), San Francisco; and University of Southern California (KI, DS, DD), Los Angeles, California; Oregon Health and Science University (M.S.), Portland, Oregon; University of Texas Health Science Center (J.Ho., C.W., B.C.), Houston, Texas.

Submitted: December 3, 2012, Revised: March 12, 2013, Accepted: March 12, 2013.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

This study was presented at the 26th Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 15–19, 2013, in Scottsdale, Arizona.

Address for reprints: Juan Carlos Duchesne, MD, Section of Trauma and Critical Care Surgery, Department of Surgery, Anesthesia, Emergency Medicine, Tulane University School of Medicine, 1430 Tulane Ave, SL-22, New Orleans, LA 70112-2699; email:

© 2013 Lippincott Williams & Wilkins, Inc.