Pro-Con Debate: Formulaic Approach Using Fixed Ratios of Blood Components Versus Targeted Therapy Approach Guided By Viscoelastic Hemostatic Assays for Resuscitation in Traumatic Major Hemorrhage

There are two different approaches to hemostatic resuscitation used in major hemorrhage protocols for critically bleeding trauma patients: A formulaic approach using fixed ratios of blood components and a targeted therapy approach guided by viscoelastic hemostatic assays. There is ongoing debate with differing opinions on what constitutes the most appropriate approach. There is also widespread variation in management approaches and options used. The aim of a major hemorrhage protocol is to guide a multidisciplinary multiple strategy approach to identify the source and cause of bleeding and control it expeditiously, correct coagulopathy, and normalize physiological derangement. Proponents of a fixed-ratio blood component approach to hemostatic resuscitation in traumatic hemorrhage argue that it provides the necessary blood components, reduces cognitive load on the trauma team and standardizes clinical practice. They also argue that the alternative of target-driven therapy is currently a utopian concept, delays care, and, if instituted, may result in harm to patients, carers, and the health system. Proponents of targeted therapy hold that a formulaic fixed-ratio approach does not treat specific deficits and may result in over-transfusion of components, exposing patients to the inherent risks of blood component transfusions. They propose that a targeted approach using viscoelastic hemostatic assays reduces exposure to blood components and reduces mortality. Both proposed strategies assume ready access to blood components and/or products, investigational tools, appropriately trained multidisciplinary staff and as such are targeted toward resuscitation of critical bleeding in advanced trauma systems.