Implementation of a military-derived damage-control resuscitation strategy in a civilian trauma center decreases acute hypoxia in massively transfused patients

Abstract

Recent military experience supports a paradigm shift in shock resuscitation to damage-control resuscitation (DCR), which emphasizes a plasma-rich and crystalloid-poor approach to resuscitation. The effect of DCR on hypoxia after massive transfusion is unknown. We hypothesized that implementation of a military-derived DCR strategy in a civilian setting would lead to decreased acute hypoxia. A DCR strategy was implemented in 2007. We retrospectively reviewed patients receiving trauma surgeon operative intervention and 10 or more units of packed red blood cells (pRBCs) within 24 hours of injury at an adult Level I trauma center from 2001 to 2010. Demographic data, blood requirements, and PaO₂/FIO₂ ratios were analyzed. To evaluate evolving resuscitation strategies, we fit linear trend models to continuous variables and tested their slopes for statistical significance. Two hundred sixteen patients met the study criteria, with a mean age of 35 ± 1.1 years and Injury Severity Score (ISS) of 31 ± 9.0. Of the patients, 80% were male, and 52% sustained penetrating injuries. Overall mortality was 32%. Overall mean pRBC and fresh frozen plasma (FFP) units infused in 24 hours were 23.2 ± 1.1 and 18.6 ± 1.1, respectively. Trends for patient age, sex, mechanism of injury, ISS, highest positive end-expiratory pressure, and mean total pRBC transfused over 24 hours were not statistically different from zero. An increasing trend in FFP and platelets transfused during the first 24 hours (p < 0.0001, p = 0.04, respectively) and a decrease in the pRBC/FFP ratio (p < 0.0001) were found. The amount of crystalloid infused during the initial 24 hours decreased with time (p < 0.0001). The lowest PaO₂/FIO₂ ratio recorded during the initial 24 hours increased during the study period (p = 0.01), indicating a statistically significant reduction in hypoxia. A military-derived DCR strategy can be implemented in the civilian setting. DCR led to significant increases in FFP transfusion, decreases in crystalloid use, and acute hypoxia.