High Ratio Resuscitation in Patients with Systemic acquired Coagulopathy vs Endogenous Acute Coagulopathy

Abstract

ABSTRACT Background Two main mechanisms of coagulopathy related to trauma have been described: systemic acquired coagulopathy (SAC) and endogenous acute coagulopathy (EAC). Resuscitation with high ratios of fresh frozen plasma to packed red blood cells (FFP:PRBC) has been shown to improve patient outcomes. Systemic acquired coagulopathy is related to acidosis, hypothermia and hemodilution. Endogenous acute coagulopathy is related to severe hemorrhage and shock, with resultant effects on intrinsic clotting pathways inducing coagulopathy more rapidly than SAC. We hypothesize that high ratio resuscitation will show improved mortality outcomes for both SAC and EAC. Study Design A retrospective chart review was performed for patients at an urban level I trauma center. All patients with international normalized ratio (INR) > 1.2 during the first 6 hours after admission who received operative intervention and at least 6 units of PRBCs following traumatic injury were included. Patients with INR > 1.2 on admission were stratified to the EAC group while patients with normal admission INR with subsequent postoperative increase in INR > 1.2 were stratified into the SAC group. Transfusion ratios for FFP:PRBC were also collected for each patient. High ratio resuscitation was defined as FFP:PRBC ≥ 1:2 and low as FFP:PRBC < 1:2. Outcomes between groups were analyzed. Results Total of 95 patients met inclusion criteria. Fifty-six (59%) patients met criteria for EAC and 39 (41%) patients developed criteria for SAC during the first 6 hours of admission. The initial average base deficit was greater in EAC vs SAC patients (–6.3 vs –4.8, p = 0.03). Endogenous acute coagulopathy patients had a higher initial INR than SAC (1.4 vs 1.1, p = 0.001), and a higher average injury severity score (ISS) (27.6 vs 21.5, p = 0.03). Regarding transfusion ratios, for both EAC and SAC, a high transfusion ratio when compared to a low transfusion ratio conveyed improved mortality (EAC: 32.5 vs 81%, p = 0.01; SAC:9 vs 64.7%, p = 0.03). For high ratio resuscitation in both groups, patients with SAC showed improved mortality compared to EAC (9 vs 32.5%, p = 0.01). Conclusion For patients with EAC and SAC, a high transfusion ratio conveyed an overall improvement in mortality. However, subgroup analysis demonstrated that despite a high transfusion ratio, EAC patients continued to have a significantly higher mortality than SAC patients. Further investigations into the mechanisms involved in EAC and interventions to improve outcomes are needed. How to cite this article Duchesne J, Derenbecker R. High Ratio Resuscitation in Patients with Systemic acquired Coagulopathy vs Endogenous Acute Coagulopathy. Panam J Trauma Crit Care Emerg Surg 2014;3(2):68-72.