title: Ratio-driven resuscitation predicts early fascial closure in the combat wounded.
abstract: BACKGROUND
  Operation Iraqi Freedom and Operation Enduring Freedom have seen the highest rates of combat casualties since Vietnam. These casualties often require massive transfusion (MT) and immediate surgical attention to control hemorrhage. Clinical practice guidelines dictate ratio-driven resuscitation (RDR) for patients requiring MT. With the transition from crystalloid to blood product resuscitation, we have seen fewer open abdomens in combat casualties. We sought to determine the effect RDR has on achieving early definitive abdominal fascial closure in combat casualties undergoing exploratory laparotomy.
  
  
  METHODS
  Records of 1,977 combat casualties admitted to a single US military hospital from April 2003 to December 2011 were reviewed. Patients receiving an MT and laparotomy in theater constituted the study cohort. The cohort was divided into RDR, defined as a ratio of 0.8-U to 1.2-U packed red blood cells to 1-U fresh frozen plasma, and No-RDR groups. Age, injury patterns, mechanism of injury, injury severity, blood products, number of laparotomies, and days to fascial closure were collected. Assessed outcomes were number of days (early ≤ 2 days) and number of laparotomies to achieve fascial closure.
  
  
  RESULTS
  The mean age of the study cohort (n = 172) was 24.0 years, and mean Injury Severity Score (ISS) was 24.8. Improvised explosive device blast was the most common mechanism of injury (74.4%). The cohort was divided into RDR patients (n = 73) and no RDR (n = 99). There was no difference in mean age, mean ISS, or rate of nontherapeutic exploratory laparotomies between the groups. RDR patients had a significantly lower abdominal injury rate (34.2% vs. 72.7%, p < 0.01), had fewer laparotomies (2.7 vs. 4.3, p = 0.003), and achieved primary fascial closure faster (2.4 days vs. 7.2 days, p = 0.004). On multivariate analysis, RDR (2.74; 95% confidence interval, 1.44-5.2) was an independent predictor for early fascial closure.
  
  
  CONCLUSIONS
  Adherence to RDR guidelines resulted in significantly decreased number of abdominal operations and was identified as an independent predictor for early fascial closure. Further investigation is warranted to validate these findings.
  
  
  METHODS
  Therapeutic study, level III.
authors.affiliation: From the Walter Reed National Military Medical Center (J.G., M.V., C.C., E.E., E.H., B.B., S.S., C.R.); and Uniformed Services University of Health Sciences (E.E., S.S.), Bethesda; and Division of Trauma and Surgical Critical Care (J.G.), Department of Surgery, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland; and Memorial University Medical Center (J.D.), Savannah, Georgia.
authors.forename: Jacob
authors.initials: J
authors.lastname: Glaser
authors.forename: Matthew
authors.initials: M
authors.lastname: Vasquez
authors.forename: Cassandra
authors.initials: C
authors.lastname: Cardarelli
authors.forename: James
authors.initials: J
authors.lastname: Dunne
authors.forename: Eric
authors.initials: E
authors.lastname: Elster
authors.forename: Emily
authors.initials: E
authors.lastname: Hathaway
authors.forename: Benjamin
authors.initials: B
authors.lastname: Bograd
authors.forename: Shawn
authors.initials: S
authors.lastname: Safford
authors.forename: Carlos
authors.initials: C
authors.lastname: Rodriguez
mesh_terms: D000007:Abdominal Injuries / Q000601:surgery*; D055826:Afghan Campaign 2001-; D001753:Blast Injuries / Q000601:surgery*; D016913:Blood Component Transfusion / Q000706:statistics & numerical data*; D000071938:Fasciotomy; D005260:Female; D019983:Guideline Adherence; D006772:Hospitals, Military; D006801:Humans; D015601:Injury Severity Score; D054542:Iraq War, 2003-2011; D007813:Laparotomy / Q000379:methods; D008297:Male; D008889:Military Personnel; D011446:Prospective Studies; D012042:Registries; D012151:Resuscitation / Q000379:methods*; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult