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. Author manuscript; available in PMC: 2016 Jun 1.
Published in final edited form as: J Trauma Acute Care Surg. 2015 Jun;78(6):1237. doi: 10.1097/TA.0000000000000537

“Hemostatic resuscitation is neither hemostatic nor resuscitative in trauma hemorrhage” – but did they in fact test the effect of hemostatic resuscitation?

Jakob Stensballe 1,2, John B Holcomb 3
PMCID: PMC4495969  NIHMSID: NIHMS648630  PMID: 26151533

To the editor

Khan et al1 report an observational study of 106 trauma hemorrhage patients from the Royal London and Oxford in the UK and Oslo in Norway, receiving at least 4 RBC after arrival. The patients were severely injured with median Injury Severity Score 34, and 43% were coagulopathic on arrival. Their purpose was to address if hemostatic resuscitation corrected coagulopathy during trauma hemorrhage.

Resuscitation was done with an average FFP/RBC-ratio of 0.5 during the first phase of 0–4 RBC’s transfused, slowly catching up to a ratio 0.7 after 12 hours treatment. Furthermore, the PLT/RBC-ratio was very low 0.125. The time to start of FFP and/or PLT transfusion as well as time to bleeding control was not accounted for. According to the largest prospective study on this topic, the The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study of 1,245 patients2, these factors have a major impact on coagulopathy and mortality. Additionally, Khan et al administered a median of 2,500 mL crystalloids (IQR 1,300 – 4,000) and a median of 875 mL of colloids (IQR 0 – 1,688) in the first 12 hours. Surprisingly, 25% of the patients received more crystalloids pre-hospital (>3,000 mL) than what was accepted by the inclusion criteria i.e. < 2000 mL. In addition to survival, it is critically important to report morbidity endpoints such as ARDS, AKI and MOF. Without these data it is difficult for clinicians to compare results between different approaches to resuscitation.

The clinical practice evaluated in the study by Khan et al1 does not qualify as hemostatic resuscitation and, we therefore agree, their practice is neither hemostatic nor resuscitative. Patients received large volumes of crystalloids and colloids both in the pre- and the early in-hospital phase. This dilution at least partially explains the increase in coagulopathy from 43% of patients at arrival to 68% after 12 administered RBC’s while with true hemostatic resuscitation this rarely occurs. Higher quality studies on hemostatic resuscitation are needed to understand the essence of ratio’s, time, fluids, and hopefully this can be captured in randomized trials.3 Meanwhile, the PROMMTT2 study sets the standard of aiming for 1:1:1 high ratio’s and early availability of FFP/PLT’s and RBCs as the primary resuscitative fluids for trauma hemorrhage in order to secure the best outcome for our patients.4,5

Footnotes

The authors declare no conflicts of interest

Contributor Information

Jakob Stensballe, Email: Stensballe@rh.dk.

John B. Holcomb, Email: John.Holcomb@uth.tmc.edu.

Reference List

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