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Do not forget the cryoprecipitate: The impact of the 2019 Joint Trauma System Damage Control Resuscitation Clinical
Allyson M Hynes1, Jeremy W Cannon, Ruiqi Yan
1From the Division of Trauma and Acute Care Surgery, Department of Surgery (A.M.H., P.B.M.), and Department of Emergency Medicine (A.M.H.), Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery (J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Uniformed Services University of the Health Sciences (J.W.C.), Bethesda, Maryland; Center for Health Care Transformation and Innovation (R.Y., M.K.D.), University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma and Acute Care Surgery, Department of Surgery (D.R.S.), Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts; Division of Trauma and Acute Care Surgery, Department of Surgery (A.J.B.), The University of Chicago, Chicago, Illinois; Department of Surgery (J.P.B.), University of British Columbia, Vancouver, British Columbia, Canada; Department of Emergency Medicine (B.S.A.), Icahn School of Medicine at Mount Sinai New York, New York; Department of Biostatistics (N.M., M.K.D.), Epidemiology, and Informatics, and Department of Emergency Medicine (M.K.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Background:
The benefit of transfusion of fresh frozen plasma (FFP) and platelets in a 1:1 ratio with packed red blood cells (PRBCs) is well established; however, the benefit of a particular ratio of cryoprecipitate to PRBC is not. The Joint Trauma System updated its 2019 Damage Control Resuscitation Guideline by recommending empiric 1:1 cryoprecipitate/PRBCs. We hypothesized that patients receiving product within the cryoprecipitate/PRBC guideline range (high ratio) would have an associated reduction in mortality.
Methods:
We included adult patients in the Trauma Quality Improvement Program data registry (2013-2021) who received at least 5 U of PRBCs and 1 U of FFP within 4 hours. Death within 30 minutes, nonsurvivable injury patterns, preexisting coagulopathy, advanced directives, transfers, and burns were excluded. Patients were partitioned into high (≥1:1), medium (≥1:2 to <1:1), and low (<1:2) cryoprecipitate/PRBC ratios. Treatment effects were estimated with propensity score-weighted risk adjustment models, clustering by center. The primary outcome was 6-hour mortality. Secondary outcomes included 24-hour and inpatient mortality. Adjusting for FFP, platelets, and whole blood was included as a sensitivity analysis.
Results:
A total of 49,301 patients (high, 5,284; medium, 3,630; low, 40,387) were included. The mean age was 39, 79% were male, 58% suffered blunt trauma, and the mean Injury Severity Score was 29. Unadjusted 6-hour mortality was 11.8%, 18.8%, and 21.3% for high, medium, and low ratios. High ratio was protective as compared with low at 6 hour (adjusted odds ratio [aOR], 0.52; 95% confidence interval [CI], 0.45-0.58) and 24 hours (aOR, 0.74; 95% CI, 0.67-0.82), and medium ratio was protective as compared with low ratio at 6 hours (aOR, 0.78; 95% CI, 0.70-0.87). Blood product sensitivity analysis demonstrated that high and medium ratios were protective of 6-hour, 24-hour, and inpatient mortality.
Conclusion:
High cryoprecipitate ratios were independently associated with decreased mortality in massively transfused civilian trauma patients during the first 24 hours. Future prospective multicenter randomized trials are warranted.
Level Of Evidence:
Prognostic and Epidemiological; Level III.
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