Diluting the benefits of hemostatic resuscitation: a multi-institutional analysis

J Trauma Acute Care Surg. 2013 Jul;75(1):76-82. doi: 10.1097/TA.0b013e3182987df3.


Background: Although minimization of crystalloids is a widely adopted practice in the resuscitation of patients with severe hemorrhage, its direct impact on high-ratio resuscitation (HRR) outcomes has not been analyzed. We hypothesize that HRR patients will have worse outcomes from crystalloid use.

Methods: This was a 4-year retrospective multi-institutional analysis (MIA) of patients who received massive transfusion protocol (MTP) managed with damage-control laparotomy. Ratios of fresh frozen plasma-packed red blood cell (PRBC) were calculated and divided in two groups: HRR (1-1:2) and low-ratio resuscitation (LRR < 1:2). Major outcome of interest was to analyze the direct impact of 24-hour crystalloid volume on HRR MTP patients who received 10 or more units of PRBC. Statistical analysis included analysis of variance, Fisher's exact, Kaplan-Meier (KM) survival curves, and multiple logistic regression.

Results: Total of five Level I trauma centers participated with 451 patients who received MTP with 10 or more units of PRBC (fresh frozen plasma/PRBC ratios, n = 365 (80.9%) HRR vs. n = 86 (19.0%) LRR. Overall 24-hour KM survival for the HRR versus LRR was 85.2% versus 68.6% (p = 0.0004). The volume of crystalloids on KM survival curve in HRR MTP patients was not significant for mortality (p = 0.52). Morbidity odds ratios (95% confidence interval) for complications were not significant for HRR but were for crystalloids: bacteremia, 1.05 (1.0-1.1); adult respiratory distress syndrome, 1.13 (1.0-1.2), and acute renal failure, 1.05 (1.0-1.1).

Conclusion: Our MIA results support previous studies with decreased mortality in HRR group when compared with LRR. This is the first MIA to demonstrate increased morbidity from crystalloid use in HRR. Within all MTPs with 10 or more units of PRBC, HRR was not a predictor of morbidity, but crystalloid volume was. Caution in overzealous use of crystalloid during HRR is warranted.

Level of evidence: Therapeutic study, level IV.

Publication types

  • Comparative Study
  • Evaluation Study
  • Multicenter Study

MeSH terms

  • Adult
  • Aged
  • Blood Transfusion / methods*
  • Blood Transfusion / mortality
  • Cohort Studies
  • Crystalloid Solutions
  • Female
  • Follow-Up Studies
  • Hemorrhage / diagnosis
  • Hemorrhage / mortality
  • Hemorrhage / therapy*
  • Hemostatic Techniques
  • Hospital Mortality
  • Humans
  • Isotonic Solutions / adverse effects
  • Isotonic Solutions / therapeutic use*
  • Laparotomy / methods
  • Logistic Models
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Resuscitation / methods*
  • Resuscitation / mortality
  • Retrospective Studies
  • Risk Assessment
  • Trauma Centers
  • Treatment Outcome
  • Wounds and Injuries / diagnosis
  • Wounds and Injuries / mortality
  • Wounds and Injuries / therapy


  • Crystalloid Solutions
  • Isotonic Solutions