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Transfusion strategies and development of acute respiratory distress syndrome in combat casualty care

Park, Pauline K. MD; Cannon, Jeremy W. MD, SM; Ye, Wen PhD; Blackbourne, Lorne H. MD; Holcomb, John B. MD; Beninati, William MD; Napolitano, Lena M. MD

Journal of Trauma and Acute Care Surgery: August 2013 - Volume 75 - Issue 2 - p S238–S246
doi: 10.1097/TA.0b013e31829a8c71
Clinical Science: Clinical Outcomes

BACKGROUND Damage-control resuscitation (DCR) has been advocated to reduce mortality in military and civilian settings. However, DCR and excessive crystalloid resuscitation may be associated with a higher incidence of acute respiratory distress syndrome (ARDS). We sought to examine the impact of resuscitation strategies on ARDS development in combat casualty care.

METHODS A retrospective review of Joint Theater Trauma Registry data on US combat casualties who received at least 1 U of blood product within the first 24 hours of care was performed, cross-referenced with the cohort receiving mechanical ventilation (n = 1,475). Massive transfusion (MT, ≥10 red blood cells [RBCs] and/or whole blood in 24 hours) and volume/ratios of plasma/RBC, platelet/RBC, and crystalloid/RBC (C/RBC, crystalloid liters/RBC units) were examined using bivariate/multivariate logistic regression and local regression analyses as ARDS risk factors, controlling for age, injury severity, admission systolic blood pressure, and Glasgow Coma Scale (GCS) score.

RESULTS ARDS was identified in 95 cases (6.4%). MT was required in 550 (37.3%) of the analysis cohort. ARDS was more common in MT (46 of 550, 8.4%) versus no-MT cohort (49 of 925, 5.3%), but mortality was not different (17.4% MT vs. 16.3% no-MT). ARDS patients received significantly increased crystalloid of blood product volumes. Increased crystalloid resuscitation (C/RBC ratio > 1.5) occurred in 479 (32.7%) of 1,464 patients. Unadjusted mortality was significantly increased in the cohort with C/RBC ratio of 1.5 or less compared with those with greater than 1.5 (19.1% vs. 6.3%, p < 0.0001), but no difference in ARDS (6.5% vs. 6.6%) was identified. Platelet/RBC ratio did not impact on ARDS. Increasing plasma (odds ratio, 1.07; p = 0.0062) and crystalloid (odds ratio, 1.04; p = 0.041) volumes were confirmed as independent ARDS risk factors.

CONCLUSION In modern combat casualty care, increased plasma and crystalloid infusion were identified as independent risk factors for ARDS. These findings support a practice of decreased plasma/crystalloid transfusion in trauma resuscitation once hemorrhage control is established to achieve the mortality benefit of DCR and ARDS prevention.

LEVEL OF EVIDENCE Epidemiologic and prognostic study, level IV.

From the Division of Acute Care Surgery (P.K.P., L.M.N.), Department of Surgery, and School of Public Health (W.Y.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (J.W.C.), and Pulmonary/Critical Care Medicine (W.B.), Wilford Hall Medical Center; and US Army Institute of Surgical Research (L.H.B., J.B.H.), San Antonio, Texas.

Submitted: March 28, 2013, Revised: April 18, 2013, Accepted: May 1, 2013.

This study was presented in part at the Advanced Technology Applications for Combat Casualty Care 2010 Conference, August 16–19, 2010, in St. Pete Beach, Florida.

J.W.C. is now with the San Antonio Military Medical Center, San Antonio, Texas.

J.B.H. is now with the Center for Translational Injury Research, Division of Acute Care Surgery, University of Texas at Houston, Houston, Texas.

W.B. is now with Intermountain Healthcare, Salt Lake City, Utah.

The funding organization discussed the study design with the investigators at theoutset of the project; however, it had no role in the design and conduct of thestudy; in the collection, analysis, and interpretation of the data; or in the preparation or review of the manuscript. The manuscript was reviewed for operational security and public affairs compliance according to the Department of Defense policy.

The opinions expressed in this document are solely those of the authors and do not represent an endorsement by or the views of the US Air Force, the US Army, the Department of Defense, or the US Government.

Address for reprints: Lena M. Napolitano, MD, Division of Acute Care Surgery [Trauma, Burn, Surgical Critical Care, Emergency Surgery] Department of Surgery, 1C421 University Hospital, Box 0033, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0033; email:

© 2013 Lippincott Williams & Wilkins, Inc.