DCR: Tout ne réduit pas la mortalité à l'hôpital ?

After 800 MTP Events, Mortality due To Hemorrhagic Shock Remains High And Unchanged Despite Several In-Hospital Hemorrhage Control Advancements

Duchesne, J et Al.  SHOCK: May 27, 2021 doi: 10.1097/SHK.0000000000001817
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La mise en oeuvre de moyens adaptés d'hémostase comme le REBOA est proposé dans une stratégie de DCR conduite à l'hôpital. Pourtant cette publication ne milite pas pour une amélioration de la survie de patients présentants un trauma pénétrants et requérants une transfusion massive. Seules la pose de garrot et la transfusion de sang total permettent de réduire la mortalité dans un système de prise en charge adapté.  La réalisation encore plus précoce pourrait être une solution.

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Background: 
Numerous advancements in hemorrhage control and volume replacement that comprise damage control resuscitation (DCR) have been implemented in the last decade to reduce deaths from bleeding. We sought to determine the impact of DCR interventions on mortality over 12 years in a massive transfusion protocol (MTP) population. We hypothesized that mortality would be decreased in later years, which would have used more DCR interventions.

Study Design: 
This was a retrospective review of all MTP patients treated at a large regional Level I trauma center from 2008–2019. Interventions by year of implementation examined included MTP 1:1 ratio (2009), liquid plasma (2010), tranexamic acid (2012), pre-hospital tourniquets (2013), REBOA/TEG (2017), satellite blood station (2018), and whole blood transfusion (2019). Relative risk and odds of mortality for DCR interventions were examined.

Results: 
There were 824 MTP patients included. The cohort was primarily male (80.6%) injured by penetrating mechanism (68.1%) with median (IQR) age 31 years (23–44) and NISS 25 (16–34). Overall mortality was unchanged [(38.3% to 56.6%); P = 0.26]. Tourniquets (P = 0.02) and WB (P = 0.03) were associated with lower unadjusted mortality; only tourniquets remained significant after adjustment (OR:0.39;95%CI:0.17–0.89; P = 0.03).

Conclusions: 
Despite lower mortality with use of tourniquets and WB, mortality rates due to hemorrhage have not improved at our high MTP volume institution, suggesting implementation of new in-hospital strategies is insufficient to reduce mortality. Future efforts should be directed towards moving hemorrhage control and effective resuscitation interventions to the injury scene.