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Damage control resuscitation practices, adopted by the U.S. military in 2006, appear to have resulted in fewer deaths of salvageable patients in combat hospitals, according to results of a new study.
DCR, based on the principle that the coagulopathy of trauma is worsened when the balance of whole blood is disrupted, involves early administration of blood products in a balanced ratio, aggressive correction of coagulopathy, and minimization of the use of crystalloid fluids. DCR was first introduced in U.S. combat hospitals in Iraq and Afghanistan in 2005, and widely adopted the following year.
In research published online July 16 in JAMA Surgery (doi: 10.1001/jamasurg.2014.940), Dr. Nicholas R. Langan and his colleagues at Madigan Army Medical Center in Tacoma, Wash., used data from the military’s Joint Theater Trauma Registry database to analyze records from 2,565 soldiers who died in forward combat hospitals between 2002 and 2011. The researchers looked at injury types and Injury Severity Scores (ISSs); the timing and location of death; and initial (24-hour) and total volume of blood products and fluid administered before and after DCR became standard care.
The investigators found that the wide adoption of DCR resulted in a decrease in mean 24-hour crystalloid infusion volume (6.1-3.2 L) and an increase in fresh frozen plasma use (3.2-10.1 U) (P less than .05 for both). The mean ratio of packed red blood cells to fresh frozen plasma changed from 2.6:1 during the pre-DCR period to 1.4:1 (P less than .01). The researchers also saw mean ISS increase between cohorts (23 before DCR vs. 27; P less than .05), and a shift in injury patterns favoring more severe head trauma in the DCR-era cohort.
"We believe that this represents a logical second-order effect of improved early care and resuscitation (namely, that there is improved salvage of less severely injured patients and a decreased number of deaths among those with potentially survivable injuries)," Dr. Langan and his colleagues wrote in their analysis.
Comparing the pre-DCR and DCR periods, the researchers found that both the mean ISS and the percentage of patients with severe injury increased (from a mean ISS of 22.5 to 26.7 and from 63.5% to 79.7%, respectively; P less than .05). The mean Revised Trauma Score was lower (indicating more severe injury) for the DCR cohort (4.76) than for the pre-DCR cohort (5.67) (P less than .001). And the mean probability of survival based on trauma and injury scores dropped from 77% in the pre-DCR period to 64% after 2006 (P less than .001).
There remains "significant debate about the efficacy and application of DCR that will require prospective controlled studies to resolve," the researchers wrote.
Dr. Langan and his colleagues disclosed no conflicts of interest.
While many changes occurred during this decade of war, perhaps the most significant was how resuscitation evolved. Crystalloid use plummeted, and a balanced approach to blood products transfusion became the norm.
As a strong testament to the power of the Joint Trauma System, it is important to note that research teams were deployed; protocols approved; data collected, entered into a database, and analyzed; guidelines promulgated; articles published; and changes made, all while the war was ongoing. Literally hundreds of civilians, U.S. military personnel, and collation partners worked tirelessly to accomplishment this feat.
Clearly published but unfortunately largely overlooked by the military leadership is the finding that a large percentage of both prehospital and hospital combat deaths are potentially preventable. In addition, there are less-than-optimal outcomes (not resulting in death) that routinely occur. Both of these findings deserve to be given equal attention and to receive an immediate response. Data on these potentially preventable adverse outcomes should be compiled on a weekly basis by the Joint Trauma System. They then need to be reviewed by the U.S. Secretary of Defense, and each adverse outcome should serve as an immediate catalyst for focused research efforts and rapid system change.
Dr. John B. Holcomb is with the University of Texas Health Science Center in Houston. He disclosed no conflicts of interest.
While many changes occurred during this decade of war, perhaps the most significant was how resuscitation evolved. Crystalloid use plummeted, and a balanced approach to blood products transfusion became the norm.
As a strong testament to the power of the Joint Trauma System, it is important to note that research teams were deployed; protocols approved; data collected, entered into a database, and analyzed; guidelines promulgated; articles published; and changes made, all while the war was ongoing. Literally hundreds of civilians, U.S. military personnel, and collation partners worked tirelessly to accomplishment this feat.
Clearly published but unfortunately largely overlooked by the military leadership is the finding that a large percentage of both prehospital and hospital combat deaths are potentially preventable. In addition, there are less-than-optimal outcomes (not resulting in death) that routinely occur. Both of these findings deserve to be given equal attention and to receive an immediate response. Data on these potentially preventable adverse outcomes should be compiled on a weekly basis by the Joint Trauma System. They then need to be reviewed by the U.S. Secretary of Defense, and each adverse outcome should serve as an immediate catalyst for focused research efforts and rapid system change.
Dr. John B. Holcomb is with the University of Texas Health Science Center in Houston. He disclosed no conflicts of interest.
While many changes occurred during this decade of war, perhaps the most significant was how resuscitation evolved. Crystalloid use plummeted, and a balanced approach to blood products transfusion became the norm.
As a strong testament to the power of the Joint Trauma System, it is important to note that research teams were deployed; protocols approved; data collected, entered into a database, and analyzed; guidelines promulgated; articles published; and changes made, all while the war was ongoing. Literally hundreds of civilians, U.S. military personnel, and collation partners worked tirelessly to accomplishment this feat.
Clearly published but unfortunately largely overlooked by the military leadership is the finding that a large percentage of both prehospital and hospital combat deaths are potentially preventable. In addition, there are less-than-optimal outcomes (not resulting in death) that routinely occur. Both of these findings deserve to be given equal attention and to receive an immediate response. Data on these potentially preventable adverse outcomes should be compiled on a weekly basis by the Joint Trauma System. They then need to be reviewed by the U.S. Secretary of Defense, and each adverse outcome should serve as an immediate catalyst for focused research efforts and rapid system change.
Dr. John B. Holcomb is with the University of Texas Health Science Center in Houston. He disclosed no conflicts of interest.
Damage control resuscitation practices, adopted by the U.S. military in 2006, appear to have resulted in fewer deaths of salvageable patients in combat hospitals, according to results of a new study.
DCR, based on the principle that the coagulopathy of trauma is worsened when the balance of whole blood is disrupted, involves early administration of blood products in a balanced ratio, aggressive correction of coagulopathy, and minimization of the use of crystalloid fluids. DCR was first introduced in U.S. combat hospitals in Iraq and Afghanistan in 2005, and widely adopted the following year.
In research published online July 16 in JAMA Surgery (doi: 10.1001/jamasurg.2014.940), Dr. Nicholas R. Langan and his colleagues at Madigan Army Medical Center in Tacoma, Wash., used data from the military’s Joint Theater Trauma Registry database to analyze records from 2,565 soldiers who died in forward combat hospitals between 2002 and 2011. The researchers looked at injury types and Injury Severity Scores (ISSs); the timing and location of death; and initial (24-hour) and total volume of blood products and fluid administered before and after DCR became standard care.
The investigators found that the wide adoption of DCR resulted in a decrease in mean 24-hour crystalloid infusion volume (6.1-3.2 L) and an increase in fresh frozen plasma use (3.2-10.1 U) (P less than .05 for both). The mean ratio of packed red blood cells to fresh frozen plasma changed from 2.6:1 during the pre-DCR period to 1.4:1 (P less than .01). The researchers also saw mean ISS increase between cohorts (23 before DCR vs. 27; P less than .05), and a shift in injury patterns favoring more severe head trauma in the DCR-era cohort.
"We believe that this represents a logical second-order effect of improved early care and resuscitation (namely, that there is improved salvage of less severely injured patients and a decreased number of deaths among those with potentially survivable injuries)," Dr. Langan and his colleagues wrote in their analysis.
Comparing the pre-DCR and DCR periods, the researchers found that both the mean ISS and the percentage of patients with severe injury increased (from a mean ISS of 22.5 to 26.7 and from 63.5% to 79.7%, respectively; P less than .05). The mean Revised Trauma Score was lower (indicating more severe injury) for the DCR cohort (4.76) than for the pre-DCR cohort (5.67) (P less than .001). And the mean probability of survival based on trauma and injury scores dropped from 77% in the pre-DCR period to 64% after 2006 (P less than .001).
There remains "significant debate about the efficacy and application of DCR that will require prospective controlled studies to resolve," the researchers wrote.
Dr. Langan and his colleagues disclosed no conflicts of interest.
Damage control resuscitation practices, adopted by the U.S. military in 2006, appear to have resulted in fewer deaths of salvageable patients in combat hospitals, according to results of a new study.
DCR, based on the principle that the coagulopathy of trauma is worsened when the balance of whole blood is disrupted, involves early administration of blood products in a balanced ratio, aggressive correction of coagulopathy, and minimization of the use of crystalloid fluids. DCR was first introduced in U.S. combat hospitals in Iraq and Afghanistan in 2005, and widely adopted the following year.
In research published online July 16 in JAMA Surgery (doi: 10.1001/jamasurg.2014.940), Dr. Nicholas R. Langan and his colleagues at Madigan Army Medical Center in Tacoma, Wash., used data from the military’s Joint Theater Trauma Registry database to analyze records from 2,565 soldiers who died in forward combat hospitals between 2002 and 2011. The researchers looked at injury types and Injury Severity Scores (ISSs); the timing and location of death; and initial (24-hour) and total volume of blood products and fluid administered before and after DCR became standard care.
The investigators found that the wide adoption of DCR resulted in a decrease in mean 24-hour crystalloid infusion volume (6.1-3.2 L) and an increase in fresh frozen plasma use (3.2-10.1 U) (P less than .05 for both). The mean ratio of packed red blood cells to fresh frozen plasma changed from 2.6:1 during the pre-DCR period to 1.4:1 (P less than .01). The researchers also saw mean ISS increase between cohorts (23 before DCR vs. 27; P less than .05), and a shift in injury patterns favoring more severe head trauma in the DCR-era cohort.
"We believe that this represents a logical second-order effect of improved early care and resuscitation (namely, that there is improved salvage of less severely injured patients and a decreased number of deaths among those with potentially survivable injuries)," Dr. Langan and his colleagues wrote in their analysis.
Comparing the pre-DCR and DCR periods, the researchers found that both the mean ISS and the percentage of patients with severe injury increased (from a mean ISS of 22.5 to 26.7 and from 63.5% to 79.7%, respectively; P less than .05). The mean Revised Trauma Score was lower (indicating more severe injury) for the DCR cohort (4.76) than for the pre-DCR cohort (5.67) (P less than .001). And the mean probability of survival based on trauma and injury scores dropped from 77% in the pre-DCR period to 64% after 2006 (P less than .001).
There remains "significant debate about the efficacy and application of DCR that will require prospective controlled studies to resolve," the researchers wrote.
Dr. Langan and his colleagues disclosed no conflicts of interest.
FROM JAMA SURGERY
Major finding: Both the mean ISS and the percentage of patients with severe injury increased (from a mean ISS of 22.5 to 26.7 and from 63.5% to 79.7%, respectively; P less than .05), suggesting that patients who died in a hospital during the DCR period were more likely to be severely injured, with a decrease in deaths among potentially salvageable patients.
Data source: Joint Theater Trauma Registry data from 2,565 combat deaths.
Disclosures: The researchers and discussant reported no conflicts.
