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Updated: May 10, 2026
Fixed Volume or Fixed Pressure: A Murine Model of Hemorrhagic Shock
Published on: June 6, 2011
Diluting the benefits of hemostatic resuscitation: a multi-institutional analysis
Juan Carlos Duchesne1, Jiselle Heaney, Chrissy Guidry
1Section of Trauma and Critical Care Surgery, Department of Surgery, Anesthesia, Emergency Medicine, Tulane University School of Medicine, New Orleans, Louisiana 70112-2699, USA. jduchesn@tulane.edu
Insights
High-ratio resuscitation (HRR) in massive transfusion protocols (MTP) is linked to lower mortality. However, excessive crystalloid use in HRR MTP patients significantly increases morbidity, including ARDS and acute renal failure.
Area of Science:
- Trauma Surgery
- Critical Care Medicine
- Hemorrhagic Shock Management
Background:
- Minimizing crystalloids is standard in severe hemorrhage resuscitation.
- The impact of crystalloids on high-ratio resuscitation (HRR) outcomes remains unclear.
- This study investigates crystalloid's role in HRR within massive transfusion protocols (MTP).
Purpose of the Study:
- To analyze the direct impact of 24-hour crystalloid volume on HRR MTP patients receiving ≥10 units of packed red blood cells (PRBC).
- To compare outcomes between HRR and low-ratio resuscitation (LRR) groups.
Main Methods:
- Retrospective multi-institutional analysis (MIA) of 451 patients over 4 years.
- Patients received MTP with damage-control laparotomy.
- Groups defined by fresh frozen plasma/PRBC ratios: HRR (1:1-1:2) and LRR (<1:2).
Main Results:
- HRR group (80.9%) showed significantly higher 24-hour survival (85.2%) than LRR (19.0%, 68.6%).
- Crystalloid volume did not significantly impact mortality in HRR MTP patients.
- Increased morbidity (bacteremia, ARDS, acute renal failure) was associated with higher crystalloid volumes in HRR.
Conclusions:
- HRR is associated with decreased mortality compared to LRR in MTP.
- This MIA is the first to show increased morbidity from crystalloid use in HRR.
- Crystalloid volume, not HRR itself, predicted morbidity; caution with crystalloid use in HRR is advised.
Background:
Although minimization of crystalloids is a widely adopted practice in the resuscitation of patients with severe hemorrhage, its direct impact on high-ratio resuscitation (HRR) outcomes has not been analyzed. We hypothesize that HRR patients will have worse outcomes from crystalloid use.
Methods:
This was a 4-year retrospective multi-institutional analysis (MIA) of patients who received massive transfusion protocol (MTP) managed with damage-control laparotomy. Ratios of fresh frozen plasma-packed red blood cell (PRBC) were calculated and divided in two groups: HRR (1-1:2) and low-ratio resuscitation (LRR < 1:2). Major outcome of interest was to analyze the direct impact of 24-hour crystalloid volume on HRR MTP patients who received 10 or more units of PRBC. Statistical analysis included analysis of variance, Fisher's exact, Kaplan-Meier (KM) survival curves, and multiple logistic regression.
Results:
Total of five Level I trauma centers participated with 451 patients who received MTP with 10 or more units of PRBC (fresh frozen plasma/PRBC ratios, n = 365 (80.9%) HRR vs. n = 86 (19.0%) LRR. Overall 24-hour KM survival for the HRR versus LRR was 85.2% versus 68.6% (p = 0.0004). The volume of crystalloids on KM survival curve in HRR MTP patients was not significant for mortality (p = 0.52). Morbidity odds ratios (95% confidence interval) for complications were not significant for HRR but were for crystalloids: bacteremia, 1.05 (1.0-1.1); adult respiratory distress syndrome, 1.13 (1.0-1.2), and acute renal failure, 1.05 (1.0-1.1).
Conclusion:
Our MIA results support previous studies with decreased mortality in HRR group when compared with LRR. This is the first MIA to demonstrate increased morbidity from crystalloid use in HRR. Within all MTPs with 10 or more units of PRBC, HRR was not a predictor of morbidity, but crystalloid volume was. Caution in overzealous use of crystalloid during HRR is warranted.
Level Of Evidence:
Therapeutic study, level IV.
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