Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients.
TL;DR: In patients undergoing DCL, implementation of DCR reduces crystalloid and blood product administration and is associated with an improvement in 30-day survival, and more importantly, DCR was associated with a significant increase in 30 day survival.
Abstract: OBJECTIVE
To determine if implementation of damage control resuscitation (DCR) in patients undergoing damage control laparotomy (DCL) translates into improved survival.
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University of Texas Health Science Center at Houston1, Medical College of Wisconsin2, Oregon Health & Science University3, University of Washington4, University of California, San Francisco5, University of Tennessee Health Science Center6, University of Southern California7, University of Alabama at Birmingham8, University of Cincinnati9, University of Arizona10, University of Toronto11, University of Maryland, Baltimore12, Sunnybrook Health Sciences Centre13, American College of Surgeons14, National Institutes of Health15
TL;DR: In this article, the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1 :1:2 ratio was evaluated.
Abstract: Importance Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials. Objective To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio. Design, Setting, and Participants Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013. Interventions Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled). Main Outcomes and Measures Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status. Results No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, −4.2% [95% CI, −9.6% to 1.1%]; P = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, −3.7% [95% CI, −10.2% to 2.7%]; P = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, −5.4% [95% CI, −10.4% to −0.5%]; P = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P P Conclusions and Relevance Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups. Trial Registration clinicaltrials.gov Identifier:NCT01545232
1,643 citations
Foothills Medical Centre1, University of Calgary2, Ghent University Hospital3, McMaster University4, Fremantle Hospital5, Tulane University6, Uppsala University7, University of Helsinki8, Loma Linda University9, University College Hospital10, Orlando Regional Medical Center11, VCU Medical Center12, University of Tartu13, University of Notre Dame14, University of Western Australia15, John Hunter Hospital16, Liverpool Hospital17, Albert Einstein Medical Center18, University of Utah19, Universidad Anáhuac México Norte20
TL;DR: The overall quality of evidence available to guide development of RECOMMENDATIONS was generally low and Appropriately designed intervention trials are urgently needed for patients with IAH and ACS.
Abstract: Purpose
To update the World Society of the Abdominal Compartment Syndrome (WSACS) consensus definitions and management statements relating to intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS).
1,100 citations
Cites background from "Damage control resuscitation is ass..."
...contamination with restoration of metabolic function at the expense of normal anatomy [8, 63, 64, 67, 68]....
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...Damage control resuscitation is increasingly being used among critically injured patients [7, 8, 10, 61]....
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...This type of resuscitation is characterized by permissive hypotension, limitation of crystalloid intravenous fluids, and delivering higher ratios of plasma and platelets to red blood cells [8]....
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University of Texas Health Science Center at Houston1, University of California, San Francisco2, Oregon Health & Science University3, University of Pittsburgh4, Medical College of Wisconsin5, University of Washington6, University of Cincinnati7, University of Texas Health Science Center at San Antonio8, University of Texas Southwestern Medical Center9, San Antonio Military Medical Center10
TL;DR: Higher plasma and platelet ratios early in resuscitation were associated with decreased mortality in patients who received transfusions of at least 3 units of blood products during the first 24 hours after admission, and among survivors at 24 hours, the subsequent risk of death by day 30 was not associated with plasma or Platelet ratios.
Abstract: Objective To relate in-hospital mortality to early transfusion of plasma and/or platelets and to time-varying plasma:red blood cell (RBC) and platelet:RBC ratios. Design Prospective cohort study documenting the timing of transfusions during active resuscitation and patient outcomes. Data were analyzed using time-dependent proportional hazards models. Setting Ten US level I trauma centers. Patients Adult trauma patients surviving for 30 minutes after admission who received a transfusion of at least 1 unit of RBCs within 6 hours of admission (n = 1245, the original study group) and at least 3 total units (of RBCs, plasma, or platelets) within 24 hours (n = 905, the analysis group). Main Outcome Measure In-hospital mortality. Results Plasma:RBC and platelet:RBC ratios were not constant during the first 24 hours (P Conclusions Higher plasma and platelet ratios early in resuscitation were associated with decreased mortality in patients who received transfusions of at least 3 units of blood products during the first 24 hours after admission. Among survivors at 24 hours, the subsequent risk of death by day 30 was not associated with plasma or platelet ratios.
843 citations
Additional excerpts
...At admission Age, y 38 (24-54) 1244 37 (24-53) 904 Male, No....
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...1) 869 Injury Severity Score 25 (16-34) 1243 26 (17-36) 905 Bleeding site, No....
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...5) 792 Partial thromboplastin time, s 27 (24-33) 1045 29 (25-35) 762 Prothrombin time, s 15 (13-17) 902 15 (14-17) 662 Hemoglobin, g/dL 11....
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...6) 904 Time to first units transfused, min RBCs 30 (12-99) 1222 25 (11-77) 905 Plasma 69 (35-133) 815b 69 (35-130) 778b Platelets 123 (81-190) 357b 121 (80-187) 343b Total units At 6 h RBCs 4 (2-7) 1224 5 (3-9) 905 Plasma 2 (0-5) 1224 4 (2-7) 905 Platelets 0 (0-6) 1224 0 (0-6) 905 At 24 h RBCs 5 (2-9) 1244 6 (4-11) 905 Plasma 4 (0-8) 1245 5 (2-9) 905 Platelets 0 (0-6) 1245 0 (0-6) 905 Unadjusted in-hospital mortality, No....
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TL;DR: The ninth edition of the ATLS course continues to emphasize one safe way to care for the trauma patient during initial assessment; it is not meant to incorporate the most advanced, cutting edge information or technology.
Abstract: T Advanced Trauma Life Support (ATLS) course was introduced in 1978 and is currently taught in more than 60 countries. It continues to be a widely accepted standard for the initial care of the trauma patient. Begun as a consensus view of recognized experts on safe initial management of a trauma patient, it combines didactic information with procedural skills, culminating with management of simulated patients. Evidence of its effectiveness includes ascertainment and retention of both knowledge and skills as well as reduced morbidity and mortality after introduction of the ATLS program. The ATLS course undergoes revision approximately every 4 years, with early editions primarily revising old and incorporating new content. The eight edition, published in 2008, established a new process for incorporating change. All content changes in that edition and all subsequent editions required evidence rather than opinion for change. Suggestions for change are submitted directly to the ATLS revision Web site, with the opportunity to provide references and the level of evidence. The ninth edition continues to rely on evidence to support changes in ATLS content. However, the major changes in the ninth edition are format and delivery changes rather than content changes. The drivers for format changes come primarily from the increasing understanding of adult education along with the educational preferences of the next generations. In both content and format, two principles in addition to level of evidence continue to guide any changes to the ATLS course. The course continues to emphasize one safe way to care for the trauma patient during initial assessment; it is not meant to incorporate the most advanced, cutting edge information or technology. In addition, with the increasing penetrance of ATLS around the world, there is increasing variation in local resources and practice. The ATLS vision is to embrace those differences that do not affect the ultimate delivery of safe care and allow flexibility for course directors to choose safe options that reflect their local practice.
655 citations
TL;DR: In injured patients at risk for hemorrhagic shock, the prehospital administration of thawed plasma was safe and resulted in lower 30‐day mortality and a lower median prothrombin‐time ratio than standard‐care resuscitation.
Abstract: Background After a person has been injured, prehospital administration of plasma in addition to the initiation of standard resuscitation procedures in the prehospital environment may reduc
496 citations
References
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Book•
01 Jan 1989
TL;DR: Hosmer and Lemeshow as discussed by the authors provide an accessible introduction to the logistic regression model while incorporating advances of the last decade, including a variety of software packages for the analysis of data sets.
Abstract: From the reviews of the First Edition. "An interesting, useful, and well-written book on logistic regression models... Hosmer and Lemeshow have used very little mathematics, have presented difficult concepts heuristically and through illustrative examples, and have included references."- Choice "Well written, clearly organized, and comprehensive... the authors carefully walk the reader through the estimation of interpretation of coefficients from a wide variety of logistic regression models . . . their careful explication of the quantitative re-expression of coefficients from these various models is excellent." - Contemporary Sociology "An extremely well-written book that will certainly prove an invaluable acquisition to the practicing statistician who finds other literature on analysis of discrete data hard to follow or heavily theoretical."-The Statistician In this revised and updated edition of their popular book, David Hosmer and Stanley Lemeshow continue to provide an amazingly accessible introduction to the logistic regression model while incorporating advances of the last decade, including a variety of software packages for the analysis of data sets. Hosmer and Lemeshow extend the discussion from biostatistics and epidemiology to cutting-edge applications in data mining and machine learning, guiding readers step-by-step through the use of modeling techniques for dichotomous data in diverse fields. Ample new topics and expanded discussions of existing material are accompanied by a wealth of real-world examples-with extensive data sets available over the Internet.
35,847 citations
TL;DR: Applied Logistic Regression, Third Edition provides an easily accessible introduction to the logistic regression model and highlights the power of this model by examining the relationship between a dichotomous outcome and a set of covariables.
Abstract: \"A new edition of the definitive guide to logistic regression modeling for health science and other applicationsThis thoroughly expanded Third Edition provides an easily accessible introduction to the logistic regression (LR) model and highlights the power of this model by examining the relationship between a dichotomous outcome and a set of covariables. Applied Logistic Regression, Third Edition emphasizes applications in the health sciences and handpicks topics that best suit the use of modern statistical software. The book provides readers with state-of-the-art techniques for building, interpreting, and assessing the performance of LR models. New and updated features include: A chapter on the analysis of correlated outcome data. A wealth of additional material for topics ranging from Bayesian methods to assessing model fit Rich data sets from real-world studies that demonstrate each method under discussion. Detailed examples and interpretation of the presented results as well as exercises throughout Applied Logistic Regression, Third Edition is a must-have guide for professionals and researchers who need to model nominal or ordinal scaled outcome variables in public health, medicine, and the social sciences as well as a wide range of other fields and disciplines\"--
30,190 citations
TL;DR: The effects of delaying fluid resuscitation until the time of operative intervention in hypotensive patients with penetrating injuries to the torso were determined.
Abstract: Background Fluid resuscitation may be detrimental when given before bleeding is controlled in patients with trauma. The purpose of this study was to determine the effects of delaying fluid resuscitation until the time of operative intervention in hypotensive patients with penetrating injuries to the torso. Methods We conducted a prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a prehospital systolic blood pressure ≤ 90 mm Hg. The study setting was a city with a single centralized system of prehospital emergency care and a single receiving facility for patients with major trauma. Patients assigned to the immediate-resuscitation group received standard fluid resuscitation before they reached the hospital and in the trauma center, and those assigned to the delayed-resuscitation group received intravenous cannulation but no fluid resuscitation until they reached the operating room. Results Among the 289 patients who received...
1,840 citations
TL;DR: It is concluded that damage control is a promising approach for increased survival in exsanguinating patients with major vascular and multiple visceral penetrating abdominal injuries.
Abstract: Definitive laparotomy (DL) for penetrating abdominal wounding with combined vascular and visceral injury is a difficult surgical challenge. Physiologic derangements such as dilutional coagulopathy, hypothermia, and acidosis often preclude completion of the procedure. "Damage control" (DC), defined as initial control of hemorrhage and contamination followed by intraperitoneal packing and rapid closure, allows for resuscitation to normal physiology in the intensive care unit and subsequent definitive re-exploration. The purpose of the study was to compare the damage control technique with definitive laparotomy. Over a 3 1/2-year period, 46 patients with penetrating abdominal injuries required laparotomy and urgent transfusion of greater than 10 units packed red blood cells for exsanguination. Medical records were retrospectively reviewed for degree and pattern of injury, probability of survival, actual survival, transfusion requirements for the preoperative and postoperative phases, resuscitation and operative times, lowest perioperative temperature, pH, and HCO3. No significant differences were identified between 22 DL and 24 DC patients and actual survival rates were similar (55% DC vs. 58% DL). However, in a subset of 22 patients with major vascular injury and two or more visceral injuries (maximum injury subset), otherwise similar to the overall group, survival was markedly improved in patients treated with damage control (10 of 13, 77%*) vs. DLM (1 of 9, 11%) (Fisher's exact test, * p < 0.02). In preparation for return to the operating room, DC survivors averaged 8.4 units of packed red blood cells transfused and 10.3 units fresh frozen plasma over a mean ICU stay of 31.7 hours. Resolution of coagulopathy (mean prothrombin time/partial thromboplastin time 19.5/70.4 to 13.3/34.9), normalization of acid-base balance (mean pH/HCO3 7.37/20.6 to 7.42/24.2), and core rewarming (mean 33.2 degrees C to 37.7 degrees C) were achieved. All patients had gastrointestinal procedures at reoperation (mean operative time, 4.3 hours). We conclude that damage control is a promising approach for increased survival in exsanguinating patients with major vascular and multiple visceral penetrating abdominal injuries.
1,490 citations
TL;DR: The combination of high plasma and high platelet to RBC ratios were associated with decreased truncal hemorrhage, increased 6-hour, 24 hours, and 30-day survival, and increased intensive care unit, ventilator, and hospital-free days, with no change in multiple organ failure deaths.
Abstract: Objective:To determine the effect of blood component ratios in massive transfusion (MT), we hypothesized that increased use of plasma and platelet to red blood cell (RBC) ratios would result in decreased early hemorrhagic death and this benefit would be sustained over the ensuing hospitalization.Sum
1,023 citations