title: Diluting the benefits of hemostatic resuscitation: a multi-institutional analysis.
abstract: BACKGROUND
  Although minimization of crystalloids is a widely adopted practice in the resuscitation of patients with severe hemorrhage, its direct impact on high-ratio resuscitation (HRR) outcomes has not been analyzed. We hypothesize that HRR patients will have worse outcomes from crystalloid use.
  
  
  METHODS
  This was a 4-year retrospective multi-institutional analysis (MIA) of patients who received massive transfusion protocol (MTP) managed with damage-control laparotomy. Ratios of fresh frozen plasma-packed red blood cell (PRBC) were calculated and divided in two groups: HRR (1-1:2) and low-ratio resuscitation (LRR < 1:2). Major outcome of interest was to analyze the direct impact of 24-hour crystalloid volume on HRR MTP patients who received 10 or more units of PRBC. Statistical analysis included analysis of variance, Fisher's exact, Kaplan-Meier (KM) survival curves, and multiple logistic regression.
  
  
  RESULTS
  Total of five Level I trauma centers participated with 451 patients who received MTP with 10 or more units of PRBC (fresh frozen plasma/PRBC ratios, n = 365 (80.9%) HRR vs. n = 86 (19.0%) LRR. Overall 24-hour KM survival for the HRR versus LRR was 85.2% versus 68.6% (p = 0.0004). The volume of crystalloids on KM survival curve in HRR MTP patients was not significant for mortality (p = 0.52). Morbidity odds ratios (95% confidence interval) for complications were not significant for HRR but were for crystalloids: bacteremia, 1.05 (1.0-1.1); adult respiratory distress syndrome, 1.13 (1.0-1.2), and acute renal failure, 1.05 (1.0-1.1).
  
  
  CONCLUSIONS
  Our MIA results support previous studies with decreased mortality in HRR group when compared with LRR. This is the first MIA to demonstrate increased morbidity from crystalloid use in HRR. Within all MTPs with 10 or more units of PRBC, HRR was not a predictor of morbidity, but crystalloid volume was. Caution in overzealous use of crystalloid during HRR is warranted.
  
  
  METHODS
  Therapeutic study, level IV.
authors.affiliation: Section of Trauma and Critical Care Surgery, Department of Surgery, Anesthesia, Emergency Medicine, Tulane University School of Medicine, New Orleans, Louisiana 70112-2699, USA. jduchesn@tulane.edu
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Duchesne
authors.forename: Jiselle
authors.initials: J
authors.lastname: Heaney
authors.forename: Chrissy
authors.initials: C
authors.lastname: Guidry
authors.forename: Norman
authors.initials: N
authors.lastname: McSwain
authors.forename: Peter
authors.initials: P
authors.lastname: Meade
authors.forename: Mitchell
authors.initials: M
authors.lastname: Cohen
authors.forename: Martin
authors.initials: M
authors.lastname: Schreiber
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.forename: Dimitra
authors.initials: D
authors.lastname: Skiada
authors.forename: Demetrius
authors.initials: D
authors.lastname: Demetriades
authors.forename: John
authors.initials: J
authors.lastname: Holcomb
authors.forename: Charles
authors.initials: C
authors.lastname: Wade
authors.forename: Bryan
authors.initials: B
authors.lastname: Cotton
mesh_terms: D000328:Adult; D000368:Aged; D001803:Blood Transfusion / Q000379:methods* / Q000401:mortality; D015331:Cohort Studies; D000077324:Crystalloid Solutions; D005260:Female; D005500:Follow-Up Studies; D006470:Hemorrhage / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D006489:Hemostatic Techniques; D017052:Hospital Mortality; D006801:Humans; D007552:Isotonic Solutions / Q000009:adverse effects / Q000627:therapeutic use*; D007813:Laparotomy / Q000379:methods; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012151:Resuscitation / Q000379:methods* / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D014193:Trauma Centers; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000175:diagnosis / Q000401:mortality / Q000628:therapy
chemical_list: D000077324:Crystalloid Solutions; D007552:Isotonic Solutions