title: A paradigm shift in trauma resuscitation: evaluation of evolving massive transfusion practices.
abstract: OBJECTIVE
  The evolution of damage control strategies has led to significant changes in the use of resuscitation after traumatic injury.
  
  
  OBJECTIVE
  To evaluate changes in the administration of fluids and blood products, hypothesizing that a reduction in crystalloid volume and a reduced red blood cell (RBC) to fresh frozen plasma (FFP) ratio over the last 7 years would correlate with better resuscitation outcomes.
  
  
  METHODS
  Observational prospective cohort study.
  
  
  METHODS
  Urban level I trauma center.
  
  
  METHODS
  A total of 174 trauma patients receiving a massive transfusion (>10 units of RBCs in 24 hours) or requiring the activation of the institutional massive transfusion protocol from February 2005 to June 2011.
  
  
  METHODS
  Patients had to either receive a massive transfusion or require the activation of the institutional massive transfusion protocol.
  
  
  METHODS
  In-hospital mortality.
  
  
  RESULTS
  The mean (SD) Injury Severity Score was 28.4 (16.2), the mean (SD) base deficit was -9.8 (6.3), and median international normalized ratio was 1.3 (interquartile range, 1.2-1.6); the mortality rate was 40.8%. Patients received a median of 6.1 L of crystalloid, 13 units of RBCs, 10 units of FFP, and 1 unit of platelets over 24 hours, with a mean RBC:FFP ratio of 1.58:1. The mean 24-hour crystalloid infusion volume and number of the total blood product units given in the first 24 hours decreased significantly over the study period (P < .05). The RBC:FFP ratio decreased from a peak of 1.84:1 in 2007 to 1.55:1 in 2011 (P = .20). Injury severity and mortality remained stable over the study period. When adjusted for age and injury characteristics using Cox regression, each decrease of 0.1 achieved in the massive transfusion protocol's RBC:FFP ratio was associated with a 5.6% reduction in mortality (P = .005).
  
  
  CONCLUSIONS
  There has been a shift toward a reduced crystalloid volume and the recreation of whole blood from component products in resuscitation. These changes are associated with markedly improved outcomes and a new paradigm in the resuscitation of severely injured patients.
authors.affiliation: Department of Surgery, San Francisco General Hospital, University of California.
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Kutcher
authors.forename: Lucy Z
authors.initials: LZ
authors.lastname: Kornblith
authors.forename: Raja
authors.initials: R
authors.lastname: Narayan
authors.forename: Vivian
authors.initials: V
authors.lastname: Curd
authors.forename: Aaron T
authors.initials: AT
authors.lastname: Daley
authors.forename: Brittney J
authors.initials: BJ
authors.lastname: Redick
authors.forename: Mary F
authors.initials: MF
authors.lastname: Nelson
authors.forename: Eberhard W
authors.initials: EW
authors.lastname: Fiebig
authors.forename: Mitchell J
authors.initials: MJ
authors.lastname: Cohen
mesh_terms: D000328:Adult; D001803:Blood Transfusion / Q000639:trends*; D000077324:Crystalloid Solutions; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D019934:International Normalized Ratio; D007552:Isotonic Solutions / Q000008:administration & dosage; D008297:Male; D009104:Multiple Trauma / Q000401:mortality* / Q000628:therapy*; D011446:Prospective Studies; D012151:Resuscitation / Q000401:mortality* / Q000639:trends*; D015996:Survival Rate; D014193:Trauma Centers
chemical_list: D000077324:Crystalloid Solutions; D007552:Isotonic Solutions