Mar
2014

Hemostatic resuscitation is neither hemostatic nor resuscitative in trauma hemorrhage.

Khan S, Brohi K, Chana M, et al.
J Trauma Acute Care Surg 2014;76:561-568.
NATA Rating :
Review by : J. Stensballe
NATA Review

Khan and co-authors state that “haemostatic resuscitation is neither haemostatic nor resuscitative in trauma haemorrhage” – but did they in fact test the effects of haemostatic resuscitation?

The authors conducted a prospective cohort study in 106 patients with trauma-induced haemorrhage who were admitted to three major trauma centres in London, Oxford and Oslo over a 52-month period and received at least 4 RBC units. The patients were severely injured (median Injury Severity Score of 34) and a high proportion (43%) were coagulopathic on admission. The purpose of the study was to determine whether haemostatic resuscitation corrected coagulopathy during trauma haemorrhage.

The average FFP/RBC ratio was 0.5 during the first phase (0-4 RBC units transfused), slowly catching up to a ratio 0.7 after 12 hours. The PLT/RBC ratio was very low (0.125). Neither the time to FFP and PLT transfusion nor bleeding control were accounted for. According to the largest prospective study on this topic, the PROMMTT study, which included 1200 patients, these factors affect coagulopathy and mortality, setting the standard of aiming for a 1:1:1 ratio. Furthermore, in the first 12 hours a median of 2500 mL (IQR 1300-4000) of crystalloids and a median of 875 mL (IQR 0-1688) of colloids were administered. Surprisingly, 25% of the patients received more crystalloids (>3000 mL) in the prehospital phase than what was accepted by the inclusion criteria (i.e. <2000 mL). The practice evaluated in this study does not qualify as haemostatic resuscitation and, therefore, is neither haemostatic nor resuscitative! Patients received large volumes of crystalloids and colloids both in the pre- and the early in-hospital phase. The dilution explains the increase in coagulopathy from 43% of patients on arrival to 68% after 12 administered RBC units. Future studies on haemostatic resuscitation are needed to understand the essence of ratios, time, fluids, and hopefully from high-level randomised trials. Meanwhile, we should aim for 1:1:1 ratios and early availability of FFP/PLT for trauma haemorrhage. – Jakob Stensballe