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Earlier time to hemostasis is associated with decreased mortality and rate of complications

Results from the Pragmatic Randomized Optimal Platelet and Plasma Ratio trial

Chang, Ronald MD; Kerby, Jeffrey D. MD, PhD; Kalkwarf, Kyle J. MD; Van Belle, Gerald PhD; Fox, Erin E. PhD; Cotton, Bryan A. MD, MPH; Cohen, Mitchell J. MD; Schreiber, Martin A. MD; Brasel, Karen MD, MPH; Bulger, Eileen M. MD; Inaba, Kenji MD; Rizoli, Sandro MD; Podbielski, Jeanette M. BSN; Wade, Charles E. PhD; Holcomb, John B. MD PROPPR Study Group

Journal of Trauma and Acute Care Surgery: August 2019 - Volume 87 - Issue 2 - p 342–349
doi: 10.1097/TA.0000000000002263
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BACKDROP Clinicians intuitively recognize that faster time to hemostasis is important in bleeding trauma patients, but these times are rarely reported.

METHODS Prospectively collected data from the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial were analyzed. Hemostasis was predefined as no intraoperative bleeding requiring intervention in the surgical field or resolution of contrast blush on interventional radiology (IR). Patients who underwent an emergent (within 90 minutes) operating room (OR) or IR procedure were included. Mixed-effects Poisson regression with robust error variance (controlling for age, Injury Severity Score, treatment arm, injury mechanism, base excess on admission [missing values estimated by multiple imputation], and time to OR/IR as fixed effects and study site as a random effect) with modified Bonferroni corrections tested the hypothesis that decreased time to hemostasis was associated with decreased mortality and decreased incidence of acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), multiple-organ failure (MOF), sepsis, and venous thromboembolism.

RESULTS Of 680 enrolled patients, 468 (69%) underwent an emergent procedure. Patients with decreased time to hemostasis were less severely injured, had less deranged base excess on admission, and lower incidence of blunt trauma (all p < 0.05). In 408 (87%) patients in whom hemostasis was achieved, every 15-minute decrease in time to hemostasis was associated with decreased 30-day mortality (RR, 0.97; 95% confidence interval [CI], 0.94–0.99), AKI (RR, 0.97; 95% CI, 0.96–0.98), ARDS (RR, 0.98; 95% CI, 0.97–0.99), MOF (RR, 0.94; 95% CI, 0.91–0.97), and sepsis (RR, 0.98; 95% CI, 0.96–0.99), but not venous thromboembolism (RR, 0.99; 95% CI, 0.96–1.03).

CONCLUSION Earlier time to hemostasis was independently associated with decreased incidence of 30-day mortality, AKI, ARDS, MOF, and sepsis in bleeding trauma patients. Time to hemostasis should be considered as an endpoint in trauma studies and as a potential quality indicator.

LEVEL OF EVIDENCE Therapeutic/care management, level III.

From the Center for Translational Injury Research (R.C., K.J.K., E.E.F., B.A.C., J.M.P., C.E.W., J.B.H.), University of Texas Health Science Center; Department of Surgery (R.C., K.J.K., E.E.F., B.A.C., C.E.W., J.B.H.), McGovern Medical School, Houston, Texas; Department of Surgery (J.D.K.), University of Alabama at Birmingham School of Medicine, Birmingham, Alabama; Department of Biostatistics and Environmental and Occupational Health Sciences (G.V.B.), University of Washington School of Medicine, Seattle, Washington; Department of Surgery (M.J.C.), University of Colorado School of Medicine, Denver, Colorado; Department of Surgery (M.A.S., K.B.), Oregon Health & Science University, Portland, Oregon; Department of Surgery (E.M.B), University of Washington School of Medicine, Seattle, Washington; Department of Surgery (K.I.), University of Southern California School of Medicine, Los Angeles, California; and Department of Surgery (S.R.), University of Toronto, Toronto, Canada.

Submitted: June 27, 2017, Revised: January 21, 2019, Accepted: January 31 2019.

Presented at the 76th Annual Meeting of the American Association for the Surgery of Trauma, September 13–16, 2017 in Baltimore, MD.

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 (www.jtrauma.com).

Address for reprints: Ronald Chang, MD, 6410 Fannin St. Suite 1100 Houston, TX 77030; email: ronald.chang@uth.tmc.edu.

Online date: March 19, 2019

© 2019 Lippincott Williams & Wilkins, Inc.