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Impact of policy change on US Army combat transfusion practices
John W Simmons1, Christopher E White, Brian J Eastridge
1United States Army Institute of Surgical Research, Fort Sam Houston, Texas 78234, USA. john.simmons@amedd.army.mil
Insights
The US Army's damage control resuscitation clinical practice guideline (CPG) improved transfusion practices for combat-wounded patients, leading to higher plasma to red blood cell ratios and less crystalloid use.
Area of Science:
- Trauma Surgery
- Resuscitation Medicine
- Military Medicine
Background:
- Clinical practice guidelines (CPGs) aim to update providers and guide decision-making, but their impact can be limited.
- In 2006, the US Army implemented a damage control resuscitation CPG, advocating for 1:1 plasma to red blood cell (RBC) ratios and restricted crystalloid use.
Purpose of the Study:
- To evaluate the association between the 2006 US Army damage control resuscitation CPG and changes in transfusion practices for combat-wounded patients.
Main Methods:
- A retrospective analysis of US service members who received massive transfusions (≥10 RBC units/24h) during Operation Iraqi Freedom/Operation Enduring Freedom.
- Patients were divided into pre- and post-CPG cohorts, comparing fresh frozen plasma (FFP):RBC ratios and crystalloid volumes.
Main Results:
- The post-CPG cohort (n=777) exhibited significantly higher FFP:RBC ratios (0.8 vs. 0.5) and reduced crystalloid administration (9 L vs. 14 L) compared to the pre-CPG cohort.
- Post-CPG patients presented with higher body temperatures and received more RBC, platelets, and plasma.
- No significant difference in overall mortality was observed between the two cohorts (19% vs. 24%).
Conclusions:
- Implementation of the damage control resuscitation CPG was associated with a significant shift towards higher FFP:RBC ratios and decreased crystalloid use in combat casualties.
- These practice changes align with damage control resuscitation principles, potentially influenced by battlefield maturity and product availability.
- Patients in the post-CPG cohort presented with improved physiological parameters, including normothermia and higher hemoglobin levels.
Background:
Clinical practice guidelines (CPGs) are used to keep providers up-to-date with the most recent literature and to guide in decision making. Adherence is typically improved although many have a muted impact. In March 2006, the US Army issued a damage control resuscitation CPG, encouraging 1:1 plasma:red blood cell (RBC) transfusions and limiting crystalloid use. The objective of this study was to determine whether the CPG was associated with a change in the transfusion practices in combat-wounded patients.
Methods:
All US service members injured in Operation Iraqi Freedom/Operation Enduring Freedom who received massive transfusions (MTs; > or = 10 RBC in 24 hours) were queried from the US Army Institute of Surgical Research transfusion database. Whole blood, when used, was counted as 1 unit of RBC, fresh frozen plasma (FFP), and platelet. Subjects were divided into pre- and post-CPG cohorts. Primary outcomes were ratios of FFP:RBC and crystalloid use.
Results:
A total of 777 MT patients were identified. The cohorts were similar in age (25 years +/- 6 years vs. 25 years +/- 6 years; p = ns) and injury severity scale score (24 +/- 12 vs. 25 +/- 12; p = ns). The post-CPG cohort was warmer (96.5 degrees F +/- 7.8 degrees F vs. 98.2 degrees F +/- 1.9 degrees F; p < 0.05) and was transfused more RBC, platelets, and plasma but received less crystalloid (17 units +/- 12 units vs. 19 units +/- 11 units, 1 unit +/- 2 units vs. 2 units +/- 3 units, 8 units +/- 8 units vs. 14 units +/- 11 units, 14 L +/- 14 L vs. 9 L +/- 13 L, respectively; p < 0.05). The post-CPG cohort also received a higher ratio transfusion (0.5 +/- 0.31 vs. 0.8 +/- 0.31; p < 0.05) representing a change in practice. Overall mortality was not different between the two groups (24 vs. 19%; p = 0.115).
Conclusions:
MT patients are now receiving a higher FFP:RBC ratio and less crystalloid after implementation of the CPG. Additionally, patients are now presenting normothermic and have higher hemoglobin levels. All of these changes are consistent with the principles of damage control resuscitation. Changes in practice were associated with implementation of the CPG, maturity of the battlefield, and increased availability of products.
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