Intent Versus Execution Failure to Achieve Balanced Resuscitation in Bleeding Trauma Patients

Objective(s): To evaluate the adherence to balanced resuscitation in the first 4 hours, and how whole blood (WB) affected the achievement of these ratios. Background: In 2014, TQIP Best Practices recommended balanced resuscitation in a 1:1:1 (RBC:FFP:PLT) ratio. A subsequent randomized trial demonstrated a reduction in mortality with 1:1:1 in hemorrhaging trauma patients. Adoption of these recommendations and study findings has yet to be evaluated. Methods: A prospective, multicenter, observational cohort study was performed at 7 academic level-1 trauma centers. Injured patients who required both blood transfusions and hemorrhage control procedures were enrolled. The primary outcome was 4-hour ratios of RBC:FFP and RBC:PLT. Patients dying in the first 60 minutes were excluded. Results: Of 1047 eligible patients, 1034 met the inclusion criteria. Overall, at 4 hours, 1:1 ratios for RBC:FFP and RBC:PLT were only achieved in 40% and 23%, respectively. Patients who achieved 1:1 for RBC:FFP (9% vs 22%) and RBC:PLT (13% vs 18%) at 4 hours had lower 28-day mortality rates; both P < 0.05. Multivariate regression confirmed an associated reduction in mortality with achievement of 1:1 ratios of RBC:FFP (OR: 0.42, 95% CI: 0.25–0.68; P < 0.001) and RBC:PLT (0.61, 95% CI: 0.37–0.98; P = 0.044). In addition, WB was associated with an increased likelihood of achieving both RBC:FFP (OR: 2.8, 95% CI: 2.14–3.62) and RBC:PLT (OR: 3.4, 95% CI: 2.55–4.62) of 1:1; both P < 0.001. Conclusions: In this prospective multi-institutional study, < 50% of patients were resuscitated in a balanced fashion. The use of WB was associated with an increased likelihood of achieving balanced ratios. Unbalanced resuscitation was associated with decreased survival.