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Hynes AM, Geng Z, Schmulevich D, Fox EE, Meador CL, Scantling DR, Holena DN, Abella BS, Young AJ, Holland S, Cacchione PZ, Wade CE, Cannon JW. Staying on target: Maintaining a balanced resuscitation during damage-control resuscitation improves survival. J Trauma Acute Care Surg 2021; 91:841-848. [PMID: 33901052 PMCID: PMC8547746 DOI: 10.1097/ta.0000000000003245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/17/2021] [Accepted: 04/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Damage-control resuscitation (DCR) improves survival in severely bleeding patients. However, deviating from balanced transfusion ratios during a resuscitation may limit this benefit. We hypothesized that maintaining a balanced resuscitation during DCR is independently associated with improved survival. METHODS This was a secondary analysis of the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. Patients receiving >3 U of packed red blood cells (PRBCs) during any 1-hour period over the first 6 hours and surviving beyond 30 minutes were included. Linear regression assessed the effect of percent time in a high-ratio range on 24-hour survival. We identified an optimal ratio and percent of time above the target ratio threshold by Youden's index. We compared patients with a 6-hour ratio above the target and above the percent time threshold (on-target) with all others (off-target). Kaplan-Meier analysis assessed the combined effect of blood product ratio and percent time over the target ratio on 24-hour and 30-day survival. Multivariable logistic regression identified factors independently associated with 24-hour and 30-day survival. RESULTS Of 1,245 PROMMTT patients, 524 met the inclusion criteria. Optimal targets were plasma/PRBC and platelet/PRBC of 0.75 (3:4) and ≥40% time spent over this threshold. For plasma/PRBC, on-target (n = 213) versus off-target (n = 311) patients were younger (median, 31 years; interquartile range, [22-50] vs. 40 [25-54]; p = 0.002) with similar injury burdens and presenting physiology. Similar patterns were observed for platelet/PRBC on-target (n = 116) and off-target (n = 408) patients. After adjusting for differences, on-target plasma/PRBC patients had significantly improved 24-hour (odds ratio, 2.25; 95% confidence interval, 1.20-4.23) and 30-day (odds ratio, 1.97; 95% confidence interval, 1.14-3.41) survival, while on-target platelet/PRBC patients did not. CONCLUSION Maintaining a high ratio of plasma/PRBC during DCR is independently associated with improved survival. Performance improvement efforts and prospective studies should capture time spent in a high-ratio range. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level II; Therapeutic, level IV.
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Affiliation(s)
- Allyson M. Hynes
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Zhi Geng
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Daniela Schmulevich
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Erin E. Fox
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Christopher L. Meador
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Dane R. Scantling
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Daniel N. Holena
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Benjamin S. Abella
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Andrew J. Young
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Sara Holland
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Pamela Z. Cacchione
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Charles E. Wade
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jeremy W. Cannon
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
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