Over 5 L of crystalloids raises morbidity
AT THE EAST SCIENTIFIC ASSEMBLY
SCOTTSDALE, ARIZ. – Morbidity increased with the use of more than 5 L of crystalloid solution during high-ratio hemostatic resuscitation, according to the results of a retrospective study of 451 trauma patients.
This is the first multicenter analysis to demonstrate the deleterious effect on morbidity in high-ratio resuscitation (HRR) patients, Dr. Juan Duchesne said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
"These patients already have acute insult, so when you add the double-hit phenomenon of crystalloids, you are definitely jeopardizing their outcomes," said Dr. Duchesne, director of the surgical intensive care unit at Tulane University, New Orleans.
The retrospective analysis included 451 patients treated at five centers in the United States. All received at least 10 units of packed red blood cells (PBRC) over 24 hours and damage control laparotomy. Of these, 365 received fresh frozen plasma (FFP) and PRBC at a ratio of at least 1:2 (HRR); the ratio was less than 1:2 (low-ratio resuscitation) in the other 86 patients.
The average Injury Severity Score was 23.5 (on a scale of 0-75), and the average FFP:PRBC ratio was 1.06 in the HRR group and 1.32 in the low-ratio resuscitation group.
As observed in other studies, patients in the HRR group had a significant survival advantage over those in the low-resuscitation group at 24 hours (85% vs. 69%; P = .0004), Dr. Duchesne said.
In 200 HRR patients with full data, an analysis of 24-hour crystalloid volume revealed that 9.5% received less than 5 L, 25% got 5-10 L, and 65.5% got more than 10 L. The 24-hour crystalloid volume was statistically different between the three subgroups (3.64 L vs. 7.81 L vs. 17.82 L; P = .0001), but there were no statistically significant differences in mortality.
The risk of certain morbidities, however, increased with crystalloid volume in the three subgroups. Rates of bacteremia rose significantly (0% [less than 5 L]), 13% [5-10 L], and 29% [more than 10 L]; P = .029), as did sepsis (0% [less than 5 L], 13% [5-10 L], and 22% [more than 10 L]); P = .028).
The differences were not significant for acute respiratory distress syndrome (1% [less than 5 L], 0% [5-10 L], and 8% [more than 10 L]; P = .163) and for acute respiratory failure (2% [less than 5 L], 12% [5-10 L], and 24% [more than 10 L]; P = .457).
In multiple logistic regression analysis, morbidity was significantly associated with 24-hour crystalloid volume (odds ratio, 1.11; P = .001), systolic blood pressure level in the emergency department (OR, 1.19; P = .043), and base deficit level in the emergency department (OR, 1.02; P = .002). Morbidity was not associated with high ratio resuscitation (OR, 1.34; P = .065), Dr. Duchesne observed.
Dr. Duchesne reported having no disclosures.