ABSTRACT
Introduction: The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial failed to demonstrate a mortality difference for hemorrhaging patients receiving a balanced (1:1:1) vs a 1:1:2 resuscitation at 24 hours and 30 days. Recent guidelines recommend earlier mortality end points for hemorrhage-control trials, and the use of contemporary statistical methods. The aim of this post hoc analysis of the PROPPR trial was to evaluate the impact of a balanced resuscitation strategy at early resuscitation time points using a Bayesian analytical framework. Methods: Bayesian hierarchical models were created to assess mortality differences at the 1, 3, 6, 12, 18, and 24 hours time points between study cohorts. Posterior probabilities and Bayes factors were calculated for each time point. Results: A 1:1:1 resuscitation displayed a 96%, 99%, 94%, 92%, 96%, and 94% probability for mortality benefit at 1, 3, 6, 12, 18, and 24 hours, respectively, when compared with a 1:1:2 approach. Associated Bayes factors for each respective time period were 21.2, 142, 14.9, 11.4, 26.4, and 15.5, indicating 'strong' to 'decisive' supporting evidence in favor of balanced transfusions. Conclusion: This analysis provides evidence in support that a 1:1:1 resuscitation has a high probability of mortality benefit when compared with a 1:1:2 strategy, especially at the newly defined more proximate time points during the resuscitative period. Researchers should consider using Bayesian approaches, along with more proximate end points when assessing hemorrhage-related mortality, for the analysis of future clinical trials. Level of evidence: Level III/Therapeutic.
ABSTRACT
BACKGROUND: While the acute management of burn injury has received substantial attention, patients may undergo additional hospital based, acute care following initial management. We conducted this study to quantify and describe patients' full hospital based, acute care needs within 30 days following an acute burn injury. METHODS: Using Florida, Nebraska, and New York state inpatient and emergency department databases, we identified adult patients discharged for an acute burn injury from January 1, 2010-November 30, 2014. The primary outcome was the frequency of hospital based, acute care (ED visit or hospital admission) within 30 days of initial discharge. Multivariable logistic regression modeling was used to identify patient factors associated with more frequent hospital based, acute care in the overall population. RESULTS: The final sample included 126,685 patients who sustained an acute burn injury and were initially managed through the ED (88.3%) or by hospital admission (11.7%). Overall, 16.5% of patients experienced at least one hospital based, acute care encounter within 30 days of discharge of their initial encounter. Most commonly, these were ED visits not undergoing hospital admission for wound care, ongoing burn care, or infectious complications. Patient-level factors associated with more frequent encounters included a history of opioid misuse or abuse (Adjusted Odds Ratio = 2.23, [95% Confidence Interval 2.01-2.47]), chronic obstructive pulmonary disease (AOR = 1.25, [1.12-1.38]), diabetes mellitus (AOR = 1.13, [1.04-1.23]), and mental health diagnoses (AOR = 1.22, [1.11-1.34]). CONCLUSIONS: Hospital based, acute care encounters are common after initial burn management. Further efforts are needed to improve the transition to outpatient care.
