title: Low-volume resuscitation for severe intraoperative hemorrhage: a step in the right direction.
abstract: The impact on outcomes resulting from crystalloids used with hemostatic close ratio resuscitation (HCRR) in intraoperative hemorrhage (IOH) has not been analyzed. We hypothesize a survival advantage in patients with IOH managed with a low-volume resuscitation (LVR) protocol during HCRR.  A 4-year case-control study was conducted to determine the impact on mortality of LVR versus conventional resuscitation efforts (CRE) during HCRR. A total of 45 patients managed with a HCRR + LVR protocol (combination Hextend® and 3% hypertonic saline) and 55 historical cohorts  managed with HCRR + CRE (lactated Ringer's) were included. Patient demographics, number of intraoperative units of packed red blood cells (PRBCs) and fresh-frozen plasma (FFP) received, and FFP:PRBC ratio were similar between groups. The mean intraoperative fluid volume was 0.76 L in  the HCRR + LVR group versus 4.7 L in the HCRR + CRE group (P = 0.003). In a linear regression model HCRR + LVR versus HCRR + CRE, mean trauma intensive care unit length of stay was 6 versus 11 days (P = 0.009); 30-day overall mortality was 11.1 versus  32.7 per cent (P = 0.009); perioperative mortality was 2.2 to 10.9 per cent (P = 0.13); and intensive care unit mortality 8.8 to 21.8 per cent (P = 0.07). LVR protocol conveyed a survival benefit to patients undergoing HCRR (odds ratio for mortality, 0.07 [95% confidence  interval 0.07-0.54]). This is the first civilian study to analyze the impact of LVR in patients managed with HCRR during IOH. Patients with IOH managed with HCRR and a predefined LVR protocol with Hextend® and 3 per cent hypertonic saline had an overall survival advantage and shorter  trauma intensive care unit length of stay. LVR can be an effective alternative to CRE when used in combination with HCRR in patients with IOH.
authors.affiliation: Tulane University Health Science Center, New Orleans, LA, USA. jduchesn@tulane.edu
authors.forename: Juan C
authors.initials: JC
authors.lastname: Duchesne
authors.forename: Chrissy
authors.initials: C
authors.lastname: Guidry
authors.forename: Jordan R H
authors.initials: JR
authors.lastname: Hoffman
authors.forename: Timothy S
authors.initials: TS
authors.lastname: Park
authors.forename: Jiselle
authors.initials: J
authors.lastname: Bock
authors.forename: Sarah
authors.initials: S
authors.lastname: Lawson
authors.forename: Peter
authors.initials: P
authors.lastname: Meade
authors.forename: Norman E
authors.initials: NE
authors.lastname: McSwain
mesh_terms: D016063:Blood Loss, Surgical / Q000401:mortality / Q000517:prevention & control*; D016022:Case-Control Studies; D000077324:Crystalloid Solutions; D017707:Erythrocyte Transfusion; D005260:Female; D005440:Fluid Therapy / Q000379:methods; D006439:Hemodynamics / Q000502:physiology; D006470:Hemorrhage / Q000401:mortality / Q000517:prevention & control*; D006489:Hemostatic Techniques; D006801:Humans; D006895:Hydroxyethyl Starch Derivatives / Q000008:administration & dosage; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007552:Isotonic Solutions / Q000008:administration & dosage; D007902:Length of Stay / Q000706:statistics & numerical data; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D010949:Plasma; D010952:Plasma Substitutes / Q000008:administration & dosage; D012151:Resuscitation / Q000379:methods*; D000077325:Ringer's Lactate; D012462:Saline Solution, Hypertonic / Q000008:administration & dosage; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D000077324:Crystalloid Solutions; D006895:Hydroxyethyl Starch Derivatives; D007552:Isotonic Solutions; D010952:Plasma Substitutes; D000077325:Ringer's Lactate; D012462:Saline Solution, Hypertonic