Supplement 20:
Should We Use Damage Control Resuscitation (DCR)?
One of the most frequently discussed potential advances in contemporary trauma care is
the concept of “DCR” [[1-4]]. DCR involves utilization of permissive hypotension, limitation of
crystalloid intravenous fluids, and delivering higher ratios of plasma and platelets to red blood
cells than has conventionally been used [[1]].
Evidence Summary:
In a single-institution, retrospective cohort study of 390 patients undergoing damage
control laparotomy, DCR patients received less crystalloids (14 L versus 5 L), packed red blood
cells (13 units versus 7 units), plasma (11 units versus 8 units), and platelets (6 units versus 0
units) as compared to those who did not receive DCR and peak IAPs were reported to be lower
in the DCR group [[1]]. Another single-center, retrospective cohort study reported that the risk
of ACS decreased (9.9% versus 0%, p<0.001) among severely injured trauma patients after
institution of a DCR trauma exsanguination protocol [[5]]. This study also reported that use of
this protocol decreased the adjusted odds of developing multi-organ failure (OR, 0.20; 95% CI,
0.11 to 0.40) and increased the adjusted odds of achieving primary abdominal fascial closure
(OR, 5.6; 95% CI, 2.5 to 12.7) [[5]].
However, a recent systematic review [[6, 7]] identified 11 observational (including three
prospective [[8-10]], seven retrospective [[11-17]], and one historical case-control [[18]]) studies
that examined treatment of trauma-associated coagulopathy with transfusion of high plasma to
packed red blood cell ratios. As several methodological limitations, including survival bias, has
limited the examination of the effect of DCR on mortality, this systematic review concluded that
insufficient evidence existed to support a survival advantage with DCR.
A summary of Studies Table is available online at Supplement A9 - Summary of
Studies for Damage Control Resuscitation.
Reccomendation:
The WSACS SUGGESTS that an enhanced ratio of plasma/packed red blood cells
should be used for resuscitation of massive hemorrhage versus low or no attention to
plasma/packed red blood cell ratios (Management suggestion 5; GRADE 2D).
Rationale:
Although DCR may avoid crystalloid over-resuscitation and possibly IAH/ACS, its
impact on many patient-important outcomes remains unknown.
References
1.
2.
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