JAMA Surgery: Cardiac Arrest/Resuscitation Topic Collection

FFP:RBC Resuscitation Ratio and Post-Shock Fluid Uptake FFP:RBC Ratio and Post-Shock Fluid Uptake

Lucas CE, Ledgerwood AM. — Fri, 01 Mar 2013 00:00:00 GMT

Objective

To assess the effects of the fresh frozen plasma (FFP) to red blood cell (RBC) ratio and balanced electrolyte solution (BES) to RBC ratio during resuscitation of severely injured patients on the duration of the postoperative fluid uptake period (phase 2) as well as the fluid (BES) needs, weight gain, and hypoproteinemia in phase 2.

Design, Setting, and Patients

The 316 patients were hypotensive (systolic blood pressure = 81 mm Hg) and tachycardic (117/min), with an average shock time (systolic blood pressure < 80 mm Hg) of 31 minutes in the operating room (OR); they received 14.2 RBC units, 854 mL of FFP, and 11.5 L of BES while in the OR. Phase 2 averaged 29.2 hours, where the patients gained 8.4 kg, had a serum albumin level of 2.6 g per day, and received 8.6 L of BES. The phase 2 time, BES needs, weight gain, and hypoproteinemia were correlated with systolic blood pressure, admission pulse rate, arterial pH, shock time, RBC, FFP, and BES; the FFP:RBC, BES:RBC, and BES:FFP ratios were given in the OR.

Results

Shock time had the best correlation with RBC, FFP, and BES administration in the OR as well as with phase 2 duration, BES needs, weight gain, and hypoproteinemia. There was no significant correlation with OR FFP:RBC, BES:RBC, or BES:FFP ratios and phase 2 hypoproteinemia or weight gain. The FFP:RBC ratio in the OR correlated directly with phase 2 duration and BES needs (P = .001); in contrast, the BES:RBC ratio in the OR correlated (P < .001) inversely with phase 2 duration and BES needs.

Conclusions

The severity of shock is best predicted by shock time and the RBC, FFP, and BES infusions in the OR. Contrary to recent reports, the FFP:RBC ratio in the OR correlates directly with duration and BES needs of phase 2, whereas the BES:RBC ratio correlates inversely with phase 2 duration and BES needs.

Surgeons Rediscover, Patient Outcomes Improve Comment on “FFP:RBC Resuscitation Ratio and Post-Shock Fluid Uptake” Surgeons Rediscover, Patient Outcomes Improve

Flint L. — Fri, 01 Mar 2013 00:00:00 GMT

For more than a century, the perfect formula for resuscitation of shock in the injured patient has been sought. The search has greatly benefitted from the curiosity and intelligence of surgeons assigned to care for combat injuries. A unique feature of combat medical care is the opportunity to blend knowledge from civilian care into strategies for care of combat injuries. The lessons learned are used to improve outcomes for combat injuries and these lessons are returned into civilian trauma practice and adjusted to improve civilian outcomes.

Association of Cryoprecipitate and Tranexamic Acid With Improved Survival Following Wartime Injury Findings From the MATTERs II Study Cryoprecipitate and Tranexamic Acid and Survival

Morrison JJ, Ross JD, Dubose JJ, et al. — Fri, 01 Mar 2013 00:00:00 GMT

Objective

To quantify the impact of fibrinogen-containing cryoprecipitate in addition to the antifibrinolytic tranexamic acid on survival in combat injured.

Design

Retrospective observational study comparing the mortality of 4 groups: tranexamic acid only, cryoprecipitate only, tranexamic acid and cryoprecipitate, and neither tranexamic acid nor cryoprecipitate. To balance comparisons, propensity scores were developed and added as covariates to logistic regression models predicting mortality.

Setting

A Role 3 Combat Surgical Hospital in southern Afghanistan.

Patients

A total of 1332 patients were identified from prospectively collected UK and US trauma registries who required 1 U or more of packed red blood cells and composed the following groups: tranexamic acid (n = 148), cryoprecipitate (n = 168), tranexamic acid/cryoprecipitate (n = 258), and no tranexamic acid/cryoprecipitate (n = 758).

Main Outcome Measure

In-hospital mortality.

Results

Injury Severity Scores were highest in the cryoprecipitate (mean [SD], 28.3 [15.7]) and tranexamic acid/cryoprecipitate (mean [SD], 26 [14.9]) groups compared with the tranexamic acid (mean [SD], 23.0 [19.2]) and no tranexamic acid/cryoprecipitate (mean [SD], 21.2 [18.5]) (P < .001) groups. Despite greater Injury Severity Scores and packed red blood cell requirements, mortality was lowest in the tranexamic acid/cryoprecipitate (11.6%) and tranexamic acid (18.2%) groups compared with the cryoprecipitate (21.4%) and no tranexamic acid/cryoprecipitate (23.6%) groups. Tranexamic acid and cryoprecipitate were independently associated with a similarly reduced mortality (odds ratio, 0.61; 95% CI, 0.42-0.89; P = .01 and odds ratio, 0.61; 95% CI, 0.40-0.94; P = .02, respectively). The combined tranexamic acid and cryoprecipitate effect vs neither in a synergy model had an odds ratio of 0.34 (95% CI, 0.20-0.58; P < .001), reflecting nonsignificant interaction (P = .21).

Conclusions

Cryoprecipitate may independently add to the survival benefit of tranexamic acid in the seriously injured requiring transfusion. Additional study is necessary to define the role of fibrinogen in resuscitation from hemorrhagic shock.