Staying on target: Maintaining a balanced resuscitation during damage-control resuscitation improves survival

J Trauma Acute Care Surg. 2021 Nov 1;91(5):841-848. doi: 10.1097/TA.0000000000003245.


Background: Damage-control resuscitation (DCR) improves survival in severely bleeding patients. However, deviating from balanced transfusion ratios during a resuscitation may limit this benefit. We hypothesized that maintaining a balanced resuscitation during DCR is independently associated with improved survival.

Methods: This was a secondary analysis of the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. Patients receiving >3 U of packed red blood cells (PRBCs) during any 1-hour period over the first 6 hours and surviving beyond 30 minutes were included. Linear regression assessed the effect of percent time in a high-ratio range on 24-hour survival. We identified an optimal ratio and percent of time above the target ratio threshold by Youden's index. We compared patients with a 6-hour ratio above the target and above the percent time threshold (on-target) with all others (off-target). Kaplan-Meier analysis assessed the combined effect of blood product ratio and percent time over the target ratio on 24-hour and 30-day survival. Multivariable logistic regression identified factors independently associated with 24-hour and 30-day survival.

Results: Of 1,245 PROMMTT patients, 524 met the inclusion criteria. Optimal targets were plasma/PRBC and platelet/PRBC of 0.75 (3:4) and ≥40% time spent over this threshold. For plasma/PRBC, on-target (n = 213) versus off-target (n = 311) patients were younger (median, 31 years; interquartile range, [22-50] vs. 40 [25-54]; p = 0.002) with similar injury burdens and presenting physiology. Similar patterns were observed for platelet/PRBC on-target (n = 116) and off-target (n = 408) patients. After adjusting for differences, on-target plasma/PRBC patients had significantly improved 24-hour (odds ratio, 2.25; 95% confidence interval, 1.20-4.23) and 30-day (odds ratio, 1.97; 95% confidence interval, 1.14-3.41) survival, while on-target platelet/PRBC patients did not.

Conclusion: Maintaining a high ratio of plasma/PRBC during DCR is independently associated with improved survival. Performance improvement efforts and prospective studies should capture time spent in a high-ratio range.

Level of evidence: Epidemiologic/prognostic study, level II; Therapeutic, level IV.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adult
  • Blood Transfusion / methods
  • Blood Transfusion / standards
  • Blood Transfusion / statistics & numerical data*
  • Female
  • Hemorrhage / etiology
  • Hemorrhage / mortality
  • Hemorrhage / therapy*
  • Hospital Mortality
  • Humans
  • Injury Severity Score
  • Kaplan-Meier Estimate
  • Male
  • Middle Aged
  • Practice Guidelines as Topic
  • Prospective Studies
  • Resuscitation / methods
  • Resuscitation / standards
  • Resuscitation / statistics & numerical data*
  • Retrospective Studies
  • Treatment Outcome
  • Wounds, Nonpenetrating / complications
  • Wounds, Nonpenetrating / diagnosis
  • Wounds, Nonpenetrating / mortality
  • Wounds, Nonpenetrating / therapy*
  • Young Adult