• Matthew E Kutcher, Lucy Z Kornblith, Raja Narayan, Vivian Curd, Aaron T Daley, Brittney J Redick, Mary F Nelson, Eberhard W Fiebig, and Mitchell J Cohen.
• Department of Surgery, San Francisco General Hospital, University of California.
• JAMA Surg. 2013 Sep 1;148(9):834-40.

ImportanceThe evolution of damage control strategies has led to significant changes in the use of resuscitation after traumatic injury.ObjectiveTo evaluate changes in the administration of fluids and blood products, hypothesizing that a reduction in crystalloid volume and a reduced red blood cell (RBC) to fresh frozen plasma (FFP) ratio over the last 7 years would correlate with better resuscitation outcomes.DesignObservational prospective cohort study.SettingUrban level I trauma center.ParticipantsA total of 174 trauma patients receiving a massive transfusion (>10 units of RBCs in 24 hours) or requiring the activation of the institutional massive transfusion protocol from February 2005 to June 2011.ExposurePatients had to either receive a massive transfusion or require the activation of the institutional massive transfusion protocol.Main Outcomes And MeasuresIn-hospital mortality.ResultsThe mean (SD) Injury Severity Score was 28.4 (16.2), the mean (SD) base deficit was -9.8 (6.3), and median international normalized ratio was 1.3 (interquartile range, 1.2-1.6); the mortality rate was 40.8%. Patients received a median of 6.1 L of crystalloid, 13 units of RBCs, 10 units of FFP, and 1 unit of platelets over 24 hours, with a mean RBC:FFP ratio of 1.58:1. The mean 24-hour crystalloid infusion volume and number of the total blood product units given in the first 24 hours decreased significantly over the study period (P < .05). The RBC:FFP ratio decreased from a peak of 1.84:1 in 2007 to 1.55:1 in 2011 (P = .20). Injury severity and mortality remained stable over the study period. When adjusted for age and injury characteristics using Cox regression, each decrease of 0.1 achieved in the massive transfusion protocol's RBC:FFP ratio was associated with a 5.6% reduction in mortality (P = .005).Conclusions And RelevanceThere has been a shift toward a reduced crystalloid volume and the recreation of whole blood from component products in resuscitation. These changes are associated with markedly improved outcomes and a new paradigm in the resuscitation of severely injured patients.

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