Do not forget the cryoprecipitate: The impact of the 2019 Joint Trauma System Damage Control Resuscitation Clinical Practice Guideline on mortality.

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.