An exploratory, hypothesis-generating, meta-analytic study of damage control resuscitation in acute hemorrhagic shock: Examining the behavior of patient morbidity and mortality in the context of plasma-to-packed red blood cell ratios

Both traumatic and nontraumatic hemorrhagic shock continues to be associated with unacceptably high mortality and morbidity. Although significant progress has been made within the transfusion science in terms of research and subsequent implementation of life-saving massive transfusion protocols, controversies persist regarding the optimal fresh frozen plasma-to-packed red blood cell (FFP-to-PRBC) ratios in the setting of hemorrhagic shock resuscitation, especially in the context of postresuscitation sequelae. To further compound the problem, there continues to be a paucity of prospective and high-quality retrospective data in this important clinical area. The goal of this hypothesis-generating, meta-analytic study was to combine data from all available high-quality literature sources in order to enhance our understanding of the relationship between FFP-to-PRBC ratios and associated morbidity/mortality across the entire reported spectrum of transfusion component combinations. Major findings of this analysis include the significant association between increasing FFP-to-PRBC ratios and decreasing mortality, as well as the concurrent increase in morbidity among survivors. More specifically, mortality odds were significantly lower with "higher" versus "lower" FFP-to-PRBC ratios (odds ratio [OR] 0.569; 95% confidence interval [CI] 0.463-0.700) in a combined cohort of 10,610 patients. At the same time, multi-organ failure was more likely to occur in the "higher" FFP-to-PRBC ratio group (OR 1.417, 95% CI 1.243-1.616). Formal studies that focus on risk-benefit aspects of higher FFP-to-PRBC ratios are needed. Research efforts should be directed at continued mortality reduction following massive transfusion while focusing on strategies designed to minimize the incidence and severity of complications among survivors of hemorrhagic shock. The current study provides a potentially useful platform for planning and implementation of future research efforts in the area of damage control resuscitation. The following core competencies are addressed in this article: Patient care, practice-based learning and improvement, systems based practice, medical knowledge