From the Center for Translational Injury Research (R.C., K.J.K., E.E.F., B.A.C., J.M.P., C.E.W., J.B.H.), University of Texas Health Science Center; Department of Surgery (R.C., K.J.K., E.E.F., B.A.C., C.E.W., J.B.H.), McGovern Medical School, Houston, Texas; Department of Surgery (J.D.K.), University of Alabama at Birmingham School of Medicine, Birmingham, Alabama; Department of Biostatistics and Environmental and Occupational Health Sciences (G.V.B.), University of Washington School of Medicine, Seattle, Washington; Department of Surgery (M.J.C.), University of Colorado School of Medicine, Denver, Colorado; Department of Surgery (M.A.S., K.B.), Oregon Health & Science University, Portland, Oregon; Department of Surgery (E.M.B), University of Washington School of Medicine, Seattle, Washington; Department of Surgery (K.I.), University of Southern California School of Medicine, Los Angeles, California; and Department of Surgery (S.R.), University of Toronto, Toronto, Canada.
The journal of trauma and acute care surgery. 2019;87(2):342-349
BACKDROP Clinicians intuitively recognize that faster time to hemostasis is important in bleeding trauma patients, but these times are rarely reported. METHODS Prospectively collected data from the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial were analyzed. Hemostasis was predefined as no intraoperative bleeding requiring intervention in the surgical field or resolution of contrast blush on interventional radiology (IR). Patients
who underwent an emergent (within 90 minutes) operating room (OR) or IR procedure were included. Mixed-effects Poisson regression with robust error variance (controlling for age, Injury Severity Score, treatment arm, injury mechanism, base excess on admission [missing values estimated by multiple imputation], and time to OR/IR as fixed effects and study site as a random effect) with modified Bonferroni corrections tested the hypothesis that decreased time to hemostasis was associated with decreased mortality and decreased incidence of acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), multiple-organ failure (MOF), sepsis, and venous thromboembolism. RESULTS Of 680 enrolled patients, 468 (69%) underwent an emergent procedure. Patients with decreased time to hemostasis were less severely injured, had less deranged base excess on admission, and lower incidence of blunt trauma (all p < 0.05). In 408 (87%) patients in whom hemostasis was achieved, every 15-minute decrease in time to hemostasis was associated with decreased 30-day mortality (RR, 0.97; 95% confidence interval [CI], 0.94-0.99), AKI (RR, 0.97; 95% CI, 0.96-0.98), ARDS (RR, 0.98; 95% CI, 0.97-0.99), MOF (RR, 0.94; 95% CI, 0.91-0.97), and sepsis (RR, 0.98; 95% CI, 0.96-0.99), but not venous thromboembolism (RR, 0.99; 95% CI, 0.96-1.03). CONCLUSION Earlier time to hemostasis was independently associated with decreased incidence of 30-day mortality, AKI, ARDS, MOF, and sepsis in bleeding trauma patients. Time to hemostasis should be considered as an endpoint in trauma studies and as a potential quality indicator. LEVEL OF EVIDENCE Therapeutic/care management, level III.