Impact of inverse ratios on patients with exsanguinating vascular injuries: should more be the new paradigm?
BACKGROUND
Resuscitation strategies in patients with severe hemorrhage have evolved throughout the years. Optimal resuscitation ratios for civilian exsanguinating vascular injuries has not been determined. We hypothesize improved outcomes in patients with exsanguinating vascular injuries when an aggressive hemostatic resuscitation is used with an inverse ratio of fresh frozen plasma (FFP) to packed red blood cell (PRBC).


METHODS
This is a 5-year retrospective analysis of vascular injuries requiring hemostatic resuscitation. Resuscitation groups by ratios of FFP/PRBC were inverse (>1:1), high (1-1:2), and low (<1:2). Patients with 10 or greater units of PRBC (massively transfused patients) were evaluated in each of the resuscitation groups. Demographics and complications throughout hospital length of stay and were compared between the resuscitation groups. Survivability Kaplan-Meier curves were generated at 6 hours and 5 days.


RESULTS
A total of 258 patients with vascular injuries required component therapy resuscitation (low, n = 78; high, n = 156; inverse, n = 24). Massively transfused patients (n = 162, 62.7%) showed a significant Kaplan-Meier survivability difference at 6 hours (low, 65.0% vs. high, 75.0% vs. inverse, 100%, p = 0.024) and at 5 days (low, 52.5% vs. high, 62.0% vs. inverse, 100%, p = 0.008). Moreover, for massively transfused patients with extremity vascular injuries (n = 65, 39%), a relationship between resuscitation ratio and amputations was significant (low vs. high vs. inverse was 36.8% vs. 12.8% vs. 0%, respectively; p = 0.033).


CONCLUSIONS
This is the first study that highlights the potential outcomes benefits of an inverse ratio of FFP-PRBC in patients with exsanguinating vascular injuries. Multi-institutional prospective analysis is needed to potentially elucidate the cytoprotective effect of FFP to validate these results.


METHODS
Therapeutic study, level IV; diagnostic study, level III.
Department of Surgery, Section of Trauma and Critical Care Surgery, Tulane New Orleans, Louisiana 70112-2699, USA.
Chrissy
C
Guidry
Jeff
J
DellaVope
Eric
E
Simms
Jiselle B
JB
Heaney
Jodran
J
Guice
Norman
N
McSwain
Peter
P
Meade
Juan C
JC
Duchesne
D000328:Adult; D001803:Blood Transfusion / Q000379:methods*; D016009:Chi-Square Distribution; D017707:Erythrocyte Transfusion / Q000379:methods; D058734:Exsanguination / Q000401:mortality / Q000628:therapy*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D010949:Plasma; D012151:Resuscitation / Q000379:methods; D012189:Retrospective Studies; D016019:Survival Analysis; D013997:Time Factors; D057772:Vascular System Injuries / Q000401:mortality / Q000628:therapy*