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Intent vs Execution: Failure to Achieve Balanced Resuscitation in Bleeding Trauma Patients
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Jan-Michael Van Gent1, *Thomas W. Clements
1, Jeremy Cannon
2, Martin Schreiber
3, Ernest Moore
4, Nicholas Namias
5, Jason L. Sperry
6, Bryan A. Cotton
11Surgery, UT Houston, Schertz, TX; 2University of Pennsylvania, Philadelphia, PA; 3Oregon Health & Science University, Portland, OR; 4University of Colorado Health Sciences Center, Denver, CO; 5University of Miami/Jackson Memorial Hospital, Miami, FL; 6University of Pittsburgh, Pittsburgh, PA
Objective(s): In 2014, TQIP Best Practice Guidelines recommended a balanced resuscitation consisting of RBC:FFP:PLT in a 1:1:1 ratio. A randomized trial subsequently demonstrated a reduction in mortality with 1:1:1 in hemorrhaging trauma patients. However, adoption of these recommendations and study findings have yet to be evaluated. Using a recent prospective trial, we sought to evaluate the adherence to balanced resuscitation in the first 4-hours from hospital arrival. Additionally, we sought to assess how whole blood (WB) affected the achievement of these ratios.
Methods: A prospective, multicenter, observational cohort study was performed at seven academic level-1 trauma centers. Injured patients at risk for massive transfusion 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 90 minutes were excluded.
Results: 1047 patients met study inclusion with an overall mortality rate of 17%. Overall, at 4-hours, 1:1 ratios for RBC:FFP and RBC:PLT were only achieved in 40% and 23%, respectively. Interestingly, as the volume of resuscitation increased, the likelihood of achieving 1:1 ratios decreased for both RBC:FFP and RBC:PLT (TABLE). Even when lowering the ratios to 2:1, only 77% (RBC:FFP) and 59% (RBC:PLT) achieved these ratios. Those who received WB as part of their resuscitation were more likely to achieve both a 1:1 ratio of RBC:FFP (53 vs. 29%) and RBC:PLT (43 vs. 18%); both p<0.001. 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 these findings 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) being associated with reduced mortality (controlling for injury severity, shock index, receipt of WB, and baseline demographics). Regression analysis also confirmed that resuscitation with WB increased the likelihood of achieving of 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 study from seven level-1 trauma centers, achieving balanced ratios of RBC:FFP and RBC:PLT were associated with improved survival. However, only half of patients were resuscitated in a balanced fashion, with the likelihood of achieving balance declining as resuscitation volumes increased. Furthermore, the use of whole blood increased the likelihood of achieving balanced ratios. This work adds to the body of literature supporting better outcomes when best practices are followed.
Achievement of 1:1 Ratios Based on Transfusion Volumes
| | <6 U RBCs, 0-4h | 6-10 U RBCs, 0-4h | 11-20 U RBCs, 0-4h | 21-30 U RBCs, 0-4h | 31-40 U RBCs, 0-4h | >40 U RBCs, 0-4h |
| 1:1, RBC:FFP | 53% | 36% | 33% | 23% | 22% | 13% |
| 1:1, RBC:PLT | 39% | 23% | 30% | 17% | 14% | 11% |
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