Improved survival after hemostatic resuscitation

Does the emperor have no clothes?

Louis J. Magnotti, Ben L. Zarzaur, Peter Fischer, Regan Williams, Adrianne L. Myers, Eric H. Bradburn, Timothy Fabian, Martin Croce

Research output: Contribution to journalArticle

62 Citations (Scopus)

Abstract

Background: In light of recent data, controversy surrounds the apparent 30-day survival benefit of patients achieving a fresh frozen plasma (FFP) to packed red blood cell (PRBC) ratio of at least 1:2 in the face of massive transfusions (MT) (≥10 units of PRBC within 24 hours of admission). We hypothesized that initial studies suffer from survival bias because they do not consider early deaths secondary to uncontrolled exsanguinating hemorrhage. To help resolve this controversy, we evaluated the temporal relationship between blood product administration and mortality in civilian trauma patients receiving MT. Methods: Patients requiring MT over a 22-month period were identified from the resuscitation registry of a Level I trauma center. Shock severity at admission and timing of shock-trauma admission, blood product administration, and death were determined. Patients were divided into high-and low-ratio groups (≥1:2 and <1:2 FFP:PRBC, respectively) and compared. Kaplan-Meier analysis and log-rank test was used to examine 24-hour survival. Results: One hundred three patients (63% blunt) were identified (66 high-ratio and 37 low-ratio). Those patients who achieved a high-ratio in 24 hours had improved survival. However, severity of shock was less in the high-group (base excess:-8.0 vs.-11.2, p = 0.028; lactate: 6.3 vs. 8.4, p = 0.03). Seventy-five patients received MT within 6 hours. Of these, 29 received a high-ratio in 6 hours. Again, severity of shock was less in the high-ratio group (base excess:-7.6 vs.-12.7, p = 0.008; lactate: 6.7 vs. 9.4, p = 0.02). For these patients, 6-hour mortality was less in the high-group (10% vs. 48%, p < 0.002). After accounting for early deaths, groups were similar from 6 hours to 24 hours. Conclusions: Improved survival was observed in patients receiving a higher plasma ratio over the first 24 hours. However, temporal analysis of mortality using shorter time periods revealed those who achieve early high-ratio are in less shock and less likely to die early from uncontrolled hemorrhage compared with those who never achieve a high-ratio. Thus, the proposed survival advantage of a high-ratio may be because of selection of those not likely to die in the first place; that is, patients die with a low-ratio not because of a low-ratio.

Original languageEnglish (US)
Pages (from-to)97-102
Number of pages6
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume70
Issue number1
DOIs
StatePublished - Jan 1 2011

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Clothing
Hemostatics
Resuscitation
Survival
Shock
Erythrocytes
Mortality
Lactic Acid
Exsanguination
Trauma Centers
Wounds and Injuries
Base Composition
Kaplan-Meier Estimate
Registries
Hemorrhage

All Science Journal Classification (ASJC) codes

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Improved survival after hemostatic resuscitation : Does the emperor have no clothes? / Magnotti, Louis J.; Zarzaur, Ben L.; Fischer, Peter; Williams, Regan; Myers, Adrianne L.; Bradburn, Eric H.; Fabian, Timothy; Croce, Martin.

In: Journal of Trauma - Injury, Infection and Critical Care, Vol. 70, No. 1, 01.01.2011, p. 97-102.

Research output: Contribution to journalArticle

Magnotti, Louis J. ; Zarzaur, Ben L. ; Fischer, Peter ; Williams, Regan ; Myers, Adrianne L. ; Bradburn, Eric H. ; Fabian, Timothy ; Croce, Martin. / Improved survival after hemostatic resuscitation : Does the emperor have no clothes?. In: Journal of Trauma - Injury, Infection and Critical Care. 2011 ; Vol. 70, No. 1. pp. 97-102.
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AU - Zarzaur, Ben L.

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AU - Williams, Regan

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AU - Bradburn, Eric H.

AU - Fabian, Timothy

AU - Croce, Martin

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N2 - Background: In light of recent data, controversy surrounds the apparent 30-day survival benefit of patients achieving a fresh frozen plasma (FFP) to packed red blood cell (PRBC) ratio of at least 1:2 in the face of massive transfusions (MT) (≥10 units of PRBC within 24 hours of admission). We hypothesized that initial studies suffer from survival bias because they do not consider early deaths secondary to uncontrolled exsanguinating hemorrhage. To help resolve this controversy, we evaluated the temporal relationship between blood product administration and mortality in civilian trauma patients receiving MT. Methods: Patients requiring MT over a 22-month period were identified from the resuscitation registry of a Level I trauma center. Shock severity at admission and timing of shock-trauma admission, blood product administration, and death were determined. Patients were divided into high-and low-ratio groups (≥1:2 and <1:2 FFP:PRBC, respectively) and compared. Kaplan-Meier analysis and log-rank test was used to examine 24-hour survival. Results: One hundred three patients (63% blunt) were identified (66 high-ratio and 37 low-ratio). Those patients who achieved a high-ratio in 24 hours had improved survival. However, severity of shock was less in the high-group (base excess:-8.0 vs.-11.2, p = 0.028; lactate: 6.3 vs. 8.4, p = 0.03). Seventy-five patients received MT within 6 hours. Of these, 29 received a high-ratio in 6 hours. Again, severity of shock was less in the high-ratio group (base excess:-7.6 vs.-12.7, p = 0.008; lactate: 6.7 vs. 9.4, p = 0.02). For these patients, 6-hour mortality was less in the high-group (10% vs. 48%, p < 0.002). After accounting for early deaths, groups were similar from 6 hours to 24 hours. Conclusions: Improved survival was observed in patients receiving a higher plasma ratio over the first 24 hours. However, temporal analysis of mortality using shorter time periods revealed those who achieve early high-ratio are in less shock and less likely to die early from uncontrolled hemorrhage compared with those who never achieve a high-ratio. Thus, the proposed survival advantage of a high-ratio may be because of selection of those not likely to die in the first place; that is, patients die with a low-ratio not because of a low-ratio.

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