Intent Vs Execution: Failure To Achieve Balanced Resuscitation In Bleeding Trauma Patients.

Abstract

Objectives: Evaluate the adherence to balanced resuscitation in the first 4-hours, and how whole blood (WB) affected the achievement of these ratios.

Summary background data: In 2014, TQIP Best Practices recommended balanced resuscitation in a 1:1:1 (RBC:FFP:PLT) ratio. A subsequent randomized trial demonstrated a reduction in mortality with 1:1:1 in hemorrhaging trauma patients. Adoption of these recommendations and study findings have yet to be evaluated.

Methods: A prospective, multicenter, observational cohort study was performed at seven academic level-1 trauma centers. Injured patients who required both blood transfusion and hemorrhage control procedures were enrolled. Primary outcome was 4-hour ratios of RBC:FFP and RBC:PLT. Patients dying in the first 60 minutes were excluded.

Results: Of 1047 eligible patients, 1034 met inclusion. Overall, at 4-hours, 1:1 ratios for RBC:FFP and RBC:PLT were only achieved in 40% and 23%, respectively. Patients who achieved 1:1 for RBC:FFP (9 vs. 22%) and RBC:PLT (13 vs. 18%) at 4-hours had lower 28-day mortality rates; both P<0.05. Multivariate regression confirmed an associated reduction in mortality with achievement of 1:1 ratios of RBC:FFP (OR 0.42, 95% C.I. 0.25-0.68; P<0.001) and RBC:PLT (0.61, 95% C.I. 0.37-0.98; P=0.044). Additionally, WB was associated with an increased likelihood of achieving both RBC:FFP (OR 2.8, 95% C.I 2.14-3.62) and RBC:PLT (OR 3.4, 95% C.I. 2.55-4.62) of 1:1; both P<0.001.

Conclusions: In this prospective multi-institutional study, <50% of patients were resuscitated in a balanced fashion. The use of WB was associated with increased likelihood of achieving balanced ratios. Unbalanced resuscitation was associated with decreased survival.