Do Experienced Nurses Benefit From Training on Bleeding Control in the Community Setting?

INTRODUCTION: Nurses' preparedness to provide hemorrhage control aid outside of the patient care setting has not been thoroughly evaluated. We evaluated nurses' preparedness to provide hemorrhage control in the prehospital setting after a proof-of-concept training event. METHODS: We performed a secondary analysis of evaluations from a voluntary hemorrhage control training offered to a group of experienced nurses. Education was provided by a nurse certified in Stop the Bleed training and using the Basic Bleeding Control 2.0 materials. The training lasted approximately 1 hour and included a didactic portion followed by hands-on practice with task trainer legs. Participants were surveyed after training to assess their preparedness to provide hemorrhage control aid using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree); comments and feedback were also requested. Mean (SD) was used to analyze Likert scale data. Content analysis was performed to identify common themes in qualitative data. RESULTS: Forty-five experienced nurses participated in the voluntary training. Nursing experience included obstetrics, pediatrics, critical care, acute care, community health, and psychiatric/mental health. Only 39% of participants reported having previously completed a similar course. After training completion, participants reported an increase in their preparedness to provide hemorrhage control aid (mean 3.47 [SD = 1.40] vs mean 4.8 SD [.04], P < .01). Major themes identified included wanting to feel prepared to help others, refreshing skills, and knowing how to respond in an emergency. DISCUSSION: Regardless of background and experience, nurses may benefit from more advanced hemorrhage control education to prepare them to provide aid in prehospital emergency settings.

Triage Accuracy of Emergency Nurses: An Evidence-Based Review.

INTRODUCTION: Accurate triage assessment by emergency nurses is essential for prioritizing patient care and providing appropriate treatment. Undertriage and overtriage remain an ongoing issue in care of patients who present to the emergency department. The purpose of this literature review was to examine factors associated with triage accuracy in the emergency department. METHODS: We conducted an evidence-based literature review using the Cumulative Index to Nursing and Allied Health Literature, PubMed, and Embase. The search focused on peer-reviewed articles in English, available in full text, published between January 2011 and December 2021. RESULTS: A total of 14 articles met inclusion criteria and revealed the following 3 themes for triage accuracy: triage nurse characteristics, patient characteristics, and work environment. Triage nurses' accuracy rates ranged from 59.3% to 82%, with experience in triage associated with higher accuracy. Patient characteristics influenced triage accuracy, with nontrauma patients being undertriaged and trauma patients often overtriaged. The work environment played a role, as accuracy rates varied based on shift time and patient volume. Competing systems between prehospital and ED triage posed challenges and affected accuracy during fluctuations in patient volumes. DISCUSSION: This review underscores the complex nature of ED triage accuracy. It highlights the importance of nurse experience, training programs, patient characteristics, and the work environment in enhancing triage decision making. Enhanced understanding of these factors can inform strategies to optimize triage accuracy and improve patient outcomes.

Epidemiology of Trauma-Related Hemorrhage and Time to Definitive Care Across North America: Making the Case for Bleeding Control Education.

INTRODUCTION: Uncontrolled trauma-related hemorrhage remains the primary preventable cause of death among those with critical injury. STUDY OBJECTIVE: The purpose of this investigation was to evaluate the types of trauma associated with critical injury and trauma-related hemorrhage, and to determine the time to definitive care among patients treated at major trauma centers who were predicted to require massive transfusion. METHODS: A secondary analysis was performed of the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) trial data (N = 680). All patients included were predicted to require massive transfusion and admitted to one of 12 North American trauma centers. Descriptive statistics were used to characterize patients, including demographics, type and mechanism of injury, source of bleeding, and receipt of prehospital interventions. Patient time to definitive care was determined using the time from activation of emergency services to responder arrival on scene, and time from scene departure to emergency department (ED) arrival. Each interval was calculated and then summed for a total time to definitive care. RESULTS: Patients were primarily white (63.8%), male (80.3%), with a median age of 34 (IQR 24-51) years. Roughly one-half of patients experienced blunt (49.0%) versus penetrating (48.2%) injury. The most common types of blunt trauma were motor vehicle injuries (83.5%), followed by falls (9.3%), other (3.6%), assaults (1.8%), and incidents due to machinery (1.8%). The most common types of penetrating injuries were gunshot wounds (72.3%), stabbings (24.1%), other (2.1%), and impalements (1.5%). One-third of patients (34.5%) required some prehospital intervention, including intubation (77.4%), chest or needle decompression (18.8%), tourniquet (18.4%), and cardiopulmonary resuscitation (CPR; 5.6%). Sources of bleeding included the abdomen (44.3%), chest (20.4%), limb/extremity (18.2%), pelvis (11.4%), and other (5.7%). Patients waited for a median of six (IQR4-10) minutes for emergency responders to arrive at the scene of injury and traveled a median of 27 (IQR 19-42) minutes to an ED. Time to definitive care was a median of 57 (IQR 44-77) minutes, with a range of 12-232 minutes. Twenty-four-hour mortality was 15% (n = 100) with 81 patients dying due to exsanguination or hemorrhage. CONCLUSION: Patients who experience critical injury may experience lengthy times to receipt of definitive care and may benefit from bystander action for hemorrhage control to improve patient outcomes.

Time to Hemostasis After Trauma and Transfusion by Patient Blood Type.

BACKGROUND: Although evidence supports an increased risk of mortality after major trauma among patients with type O blood, the relationship between patient blood type and clinical outcomes aside from mortality has not been fully elucidated. OBJECTIVE: To examine the relationship between patient blood type and time to hemostasis after trauma and massive transfusion. METHODS: A secondary analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial was performed (N = 544). Blood type was dichotomized into type O versus non-type O. It was hypothesized that patients with non-type O blood would achieve hemostasis more quickly owing to the theoretical presence of increased clotting factors. Bivariate analysis and multiple Cox regression were conducted to test this assumption. RESULTS: No significant difference was found in time to hemostasis between patients with type O blood and those with non-type O blood. However, mechanism of injury, diastolic blood pressure, and international normalized ratio affected the time to hemostasis in these trauma patients. CONCLUSION: This study showed no significant difference in time to hemostasis by blood type.

Evaluation of Stop the Bleed Training Among High School Personnel: A Qualitative Study.

BACKGROUND: Uncontrolled hemorrhage is the primary preventable cause of death following trauma. Stop the Bleed training exists to promote identification and basic treatment of life-threatening bleeding in the prehospital or community setting. Limited qualitative research is available on participant evaluation of hemorrhage control training for laypersons. OBJECTIVE: To evaluate the experience and satisfaction with Stop the Bleed training among lay community members in an urban public school setting. METHODS: Three group interviews were conducted with public high school personnel (faculty and staff) who received Stop the Bleed training. Personnel were asked to evaluate the training and provide suggestions for improvement. Responses were digitally recorded and transcribed verbatim. Content analysis for common themes was performed using NVivo. RESULTS: A total of eight participants were interviewed. Participants expressed satisfaction with hands-on training and dissatisfaction with crowded and rushed training conditions. Major themes included: (1) skill acquisition, retention, and decay, (2) training format and setting, and (3) use of simulation. CONCLUSIONS: Current Stop the Bleed training is considered satisfactory among public school educators. Suggestions for improvement include annual retraining programs and simulation-enhanced training opportunities.

Whole Blood for Resuscitation of Traumatic Hemorrhagic Shock in Adults.

Injured patients with traumatic hemorrhagic shock often require resuscitation with transfusion of red blood cells, plasma, and platelets. Resuscitation with whole blood (WB) has been used in military settings, and its use is increasingly common in civilian practice. We provide an overview of the benefits and challenges, guidelines, and unanswered questions related to the use of WB in the treatment of civilian trauma-related hemorrhage. Implications for advanced practice nurses and nursing staff are also discussed.

An Innovative Educational Trio for Physical Assessment in an Undergraduate Nursing Course.

ABSTRACT: Effective teaching methods are critical to the acquisition of physical assessment skills. This article describes the combined use of deliberate practice, standardized patient simulation, and peer evaluation in improving physical assessment skills among first-semester nursing students. Students prepared for a physical assessment check-off by using deliberate practice throughout the semester; they then received peer feedback after a standardized patient simulation. Students felt the integrated experience improved their physical assessment performance. Incorporating this innovative educational trio can provide opportunities for physical assessment skill enhancement.

Application of Bleeding Control Training in Occupational Settings.

Background: Uncontrolled blood loss is a primary source of preventable death after injury. Workplace injuries and fatalities are common, with most occurring in the agricultural/fishing/forestry/hunting or transportation/warehousing industries. Stop the Bleed (STB) training provides instruction on application of bleeding control methods to injured persons and is available to the general public. Method: We provided an overview of high-risk injury industries that could benefit from STB training. We also provided a review of the application of STB training and bleeding control methods in occupational settings with an emphasis on the role of the occupational health nurse. Findings: Suggested guidelines for occupational health nurses and employees in occupational settings who may respond to injured colleagues are provided. Implications for occupational health nurses are reviewed, including implementing STB training in the workplace and obtaining/storing bleeding control supplies. Resources for STB training, purchasing and storing bleeding control supplies, and general emergency response information are provided. Conclusions/application to practice: Occupational health nurses play a crucial role in emergency response in the workplace and have the ability to drive the implementation of STB training in their institution. Occupational health nurses often work in isolation or in small teams and serve as a primary resource for treatment of injured employees. Implementation of STB training for all employees is highly recommended given the limited availability of occupational health nurses in large or rural settings. Such training may reduce the morbidity and mortality associated with workplace injuries.

Evaluation of "Stop the Bleed" training among K-12 faculty and staff in Alabama.

OBJECTIVES: To evaluate "Stop the Bleed" (STB) training among/K12 personnel in an Alabama school system, and to assess participants' perceived readiness to train peers in STB methods. DESIGN AND SAMPLE: We performed a cross-sectional observational study with a convenience, nonprobability sample of 466 full-time personnel who received STB training. Data were collected using an anonymous online survey. MEASUREMENTS: We asked participants to recall feelings related to STB both prior to and after completing training using a 5-point Likert scale (5 = "Strongly Disagree", 1 = "Strongly Agree"). We used logistic regression to evaluate the association among posttraining feelings and perceived preparedness to train others in STB. RESULTS: Participants were primarily female (78%), aged 41 ± 10 years, who held faculty positions (94%). Results revealed increased knowledge of (4 [IQR 2-4] vs. 2 [1-2], p < .001) and comfort with (4 [2-5] vs. 2 [1-2], p < .001) STB skills. Participants felt more empowered to organize STB training (4 [3-5] vs. 3 [2-4], p < .001); those who felt empowered to organize STB training were eight times more likely to feel capable of teaching STB. CONCLUSIONS: After STB training, K-12 personnel felt empowered to organize additional STB trainings and capable of teaching STB methods to others.

Characterizing red blood cell age exposure in massive transfusion therapy: the scalar age of blood index (SBI).

BACKGROUND: The mortality of trauma patients requiring massive transfusion to treat hemorrhagic shock approaches 17% at 24 hours and 26% at 30 days. The use of stored RBCs is limited to less than 42 days, so older RBCs are delivered first to rapidly bleeding trauma patients. Patients who receive a greater quantity of older RBCs may have a higher risk for mortality. METHODS AND MATERIALS: Characterizing blood age exposure requires accounting for the age of each RBC unit and the quantity of transfused units. To address this challenge, a novel Scalar Age of Blood Index (SBI) that represents the relative distribution of RBCs received is introduced and applied to a secondary analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) randomized controlled trial (NCT01545232, https://clinicaltrials.gov/ct2/show/NCT01545232). The effect of the SBI is assessed on the primary PROPPR outcome, 24-hour and 30-day mortality. RESULTS: The distributions of blood storage ages successfully maps to a parameter (SBI) that fully defines the blood age curve for each patient. SBI was a significant predictor of 24-hour and 30-day mortality in an adjusted model that had strong predictive ability (odds ratio, 1.15 [1.01-1.29], p = 0.029, C-statistic, 0.81; odds ratio, 1.14 [1.02-1.28], p = 0.019, C-statistic, 0.88, respectively). CONCLUSION: SBI is a simple scalar metric of blood age that accounts for the relative distribution of RBCs among age categories. Transfusion of older RBCs is associated with 24-hour and 30-day mortality, after adjustment for total units and clinical covariates.

Improving Transition to Practice: Integration of Advanced Cardiac Life Support Into a Baccalaureate Nursing Program.

BACKGROUND: Nursing students often lack the skills and confidence to intervene in the care of a deteriorating patient as they transition into clinical practice. Exposure to these situations is limited during their academic career. Our team sought to address this by embedding American Heart Association (AHA) advanced cardiac life support (ACLS) content into the curriculum and offering certification to senior-level students. METHOD: The senior skills course was redesigned to include education on current AHA ACLS guidelines and skills. ACLS algorithms were introduced and reinforced by mock code labs utilizing rapid cycle deliberate practice and interprofessional simulation. After completion of the semester, students were given the option to be ACLS certified. RESULTS: Students and stakeholders reported positively on the ability to certify in ACLS at our institution prior to graduation and reported increased confidence in their ability to manage patients with cardiopulmonary arrest. CONCLUSION: Providing simulated experiences for these clinical situations can reportedly increase confidence and improve preparedness in senior-level BSN students. [J Nurs Educ. 2019;58(3):182-184.].

Older Blood Is Associated With Increased Mortality and Adverse Events in Massively Transfused Trauma Patients: Secondary Analysis of the PROPPR Trial.

STUDY OBJECTIVE: The transfusion of older packed RBCs may be harmful in critically ill patients. We seek to determine the association between packed RBC age and mortality among trauma patients requiring massive packed RBC transfusion. METHODS: We analyzed data from the Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial. Subjects in the parent trial included critically injured adult patients admitted to 1 of 12 North American Level I trauma centers who received at least 1 unit of packed RBCs and were predicted to require massive blood transfusion. The primary exposure was volume of packed RBC units transfused during the first 24 hours of hospitalization, stratified by packed RBC age category: 0 to 7 days, 8 to 14 days, 15 to 21 days, and greater than or equal to 22 days. The primary outcome was 24-hour mortality. We evaluated the association between transfused volume of each packed RBC age category and 24-hour survival, using random-effects logistic regression, adjusting for total packed RBC volume, patient age, sex, race, mechanism of injury, Injury Severity Score, Revised Trauma Score, clinical site, and trial treatment group. RESULTS: The 678 patients included in the analysis received a total of 8,830 packed RBC units. One hundred patients (14.8%) died within the first 24 hours. On multivariable analysis, the number of packed RBCs greater than or equal to 22 days old was independently associated with increased 24-hour mortality (adjusted odds ratio [OR] 1.05 per packed RBC unit; 95% confidence interval [CI] 1.01 to 1.08): OR 0.97 for 0 to 7 days old (95% CI 0.88 to 1.08), OR 1.04 for 8 to 14 days old (95% CI 0.99 to 1.09), and OR 1.02 for 15 to 21 days old (95% CI 0.98 to 1.06). Results of sensitivity analyses were similar only among patients who received greater than or equal to 10 packed RBC units. CONCLUSION: Increasing quantities of older packed RBCs are associated with increased likelihood of 24-hour mortality in trauma patients receiving massive packed RBC transfusion (≥10 units), but not in those who receive fewer than 10 units.

Using text messages to promote health in African-Americans: #HeartHealthyandCancerFree.

OBJECTIVES: African-Americans are vulnerable to both cancer and cardiovascular disease (CVD) due to intricately connected risk factors. Use of text messages is an innovative method to provide health information to reduce these risks. The aim of this study was to test the feasibility and acceptability of a text messaging intervention to reduce CVD and cancer risk factors in African-Americans. DESIGN: We developed an intervention using text messages culturally tailored for African-Americans over age 50 who were at risk (one or more modifiable risk factors) for CVD and/or cancer. Sociodemographic data, biologic measures, cancer screening practices, and general health status were assessed. Group interviews were conducted to assess feasibility and acceptability. RESULTS: Participants were primarily female (69%), aged 58 ± 5 years, who were married (59%) and worked full time (56%). In terms of feasibility and acceptability, themes of encouragement through text messages received and a desire for a longer study period emerged from group interviews with participants. Participants experienced significant decreases in waist circumference (41 ± 5 vs 40 ± 5, p = .002), systolic blood pressure (147 ± 25 mmHg vs 138 ± 20 mmHg, p = .009), diastolic blood pressure (87 ± 16 mmHg vs 82 ± 10 mmHg, p = .02), total cholesterol (194 ± 35 mg/dL vs 173 ± 32 mg/dL, p < .001), and low-density lipoprotein levels (100 ± 32 mg/dL vs 86 ± 29 mg/dL, p = .015). Five participants had colorectal cancer screening, two had prostate cancer screening, and four had mammograms. CONCLUSIONS: Use of text messages was widely accepted among participants. Significant CVD risk reductions and increased cancer screenings were noted. Future studies should incorporate innovative strategies such as text messaging in promoting health in vulnerable populations.

Packed Red Blood Cell Transfusion in Older Adults: A Systematic Review.

Most packed red blood cell (PRBC) transfusion research focuses on younger patient populations (younger than 65) given the complexity of care and presence of comorbidities in older adults. The purpose of the current study was to critically examine the current evidence related to PRBC transfusion among older adults (age ≥65). PubMed, CINAHL, and Embase were searched for randomized controlled trials that evaluated blood transfusion in any manner (e.g., prevention, associated outcomes). Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the search resulted in 10 studies focused on cardiac, orthopedic, and gastrointestinal surgery patients. SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines were used to evaluate studies for bias; the average bias score was 13.0 (SD = 3.4), indicating a low level of bias. Greatest sources of bias were methods to assess completeness/accuracy of data, details about missing data, and costs associated with the study. Interventions to prevent PRBC transfusion in older adults vary widely, and outcomes associated with PRBC transfusion in older adults require further evaluation. [Journal of Gerontological Nursing, 44(3), 39-46.].

Adverse Reactions to Transfusion of Blood Products and Best Practices for Prevention.

Transfusion, a common practice in critical care, is not without complication. Acute adverse reactions to transfusion occur within 24 hours and include acute hemolytic transfusion reaction, febrile nonhemolytic transfusion reaction, allergic and anaphylactic reactions, and transfusion-related acute lung injury, transfusion-related infection or sepsis, and transfusion-associated circulatory overload. Delayed transfusion adverse reactions develop 48 hours or more after transfusion and include erythrocyte and platelet alloimmunization, delayed hemolytic transfusion reactions, posttransfusion purpura, transfusion-related immunomodulation, transfusion-associated graft versus host disease, and, with long-term transfusion, iron overload. Clinical strategies may reduce the likelihood of reactions and improve patient outcomes.

Revised National Estimates of Emergency Department Visits for Sepsis in the United States.

OBJECTIVES: The emergency department is an important venue for initial sepsis recognition and care. We sought to determine contemporary estimates of the epidemiology of U.S. emergency department visits for sepsis. DESIGN: Analysis of data from the National Hospital Ambulatory Medical Care Survey. SETTING: U.S. emergency department visits, 2009-2011. PATIENTS: Adult (age, ≥ 18 yr) emergency department sepsis patients. We defined serious infection as an emergency department diagnosis of a serious infection or a triage temperature greater than 38°C or less than 36°C. We defined three emergency department sepsis classifications: 1) original emergency department sepsis-serious infection plus emergency department diagnosis of organ dysfunction, endotracheal intubation, or systolic blood pressure less than or equal to 90 mm Hg or explicit sepsis emergency department diagnoses; 2) quick Sequential Organ Failure Assessment emergency department sepsis-serious infection plus presence of at least two "quick" Sequential Organ Failure Assessment criteria (Glasgow Coma Scale ≤ 14, respiratory rate ≥ 22 breaths/min, or systolic blood pressure ≤ 100 mm Hg); and 3) revised emergency department sepsis-original or quick Sequential Organ Failure Assessment emergency department sepsis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used survey design and weighting variables to produce national estimates of annual adult emergency department visits using updated sepsis classifications. Over 2009-2011, there were 103,257,516 annual adult emergency department visits. The estimated number of emergency department sepsis visits were as follows: 1) original emergency department sepsis 665,319 (0.64%; 95% CI, 0.57-0.73); 2) quick Sequential Organ Failure Assessment emergency department sepsis 318,832 (0.31%; 95% CI, 0.26-0.37); and 3) revised emergency department sepsis 847,868 (0.82%; 95% CI, 0.74-0.91). CONCLUSIONS: Sepsis continues to present a major burden to U.S. emergency departments, affecting up to nearly 850,000 emergency department visits annually. Updated sepsis classifications may impact national estimates of emergency department sepsis epidemiology.

From Donor to Recipient: Considerations for Blood Transfusion Outcomes Research.

Donated blood can be broken down into blood components for use in patient care. This article focuses primarily on packed red blood cells (PRBCs), as they experience breakdown during storage that may adversely impact patient outcomes. Patients require PRBC transfusions for a number of clinical reasons. Although transfusions of PRBCs provide some clinical benefit, they are also associated with increased morbidity and mortality across multiple patient populations, albeit the mechanisms underlying this relationship remain unclear. With an aging, more acutely ill population requiring aggressive treatment and a lack of transfusion alternatives, research focused on PRBCs has gained momentum. Proper interpretation of research findings on the part of clinicians depends on accurate data collection that includes aspects of both the transfused blood components and the recipients. The purpose of this article is to examine stored PRBC factors, blood-donor characteristics, transfusion-specific factors, and patient-specific characteristics as they relate to patient outcomes research. Challenges associated with performing and interpreting outcomes of transfusion-related research are presented. Implications of current evidence for patient care, such as awareness of benefits as well as risks associated with blood component transfusion, are also provided.

Consequences of Transfusing Blood Components in Patients With Trauma: A Conceptual Model.

Transfusion of blood components is often required in resuscitation of patients with major trauma. Packed red blood cells and platelets break down and undergo chemical changes during storage (known as the storage lesion) that lead to an inflammatory response once the blood components are transfused to patients. Although some evidence supports a detrimental association between transfusion and a patient's outcome, the mechanisms connecting transfusion of stored components to outcomes remain unclear. The purpose of this review is to provide critical care nurses with a conceptual model to facilitate understanding of the relationship between the storage lesion and patients' outcomes after trauma; outcomes related to trauma, hemorrhage, and blood component transfusion are grouped according to those occurring in the short-term (≤30 days) and the long-term (>30 days). Complete understanding of these clinical implications is critical for practitioners in evaluating and treating patients given transfusions after traumatic injury.

Injury severity, sex, and transfusion volume, but not transfusion ratio, predict inflammatory complications after traumatic injury.

BACKGROUND: Blood component (packed red blood cells [PRBC], fresh frozen plasma [FFP], platelets [PLT]) ratios transfused in a 1:1:1 fashion are associated with survival after trauma; the relationship among blood component ratios and inflammatory complications after trauma is not fully understood. OBJECTIVES: To evaluate the relationship among blood component ratios (1:1 vs other for PRBC:FFP and PRBC:PLT) and inflammatory complications (primary outcome) in patients with major trauma. METHODS: Secondary analysis of a multi-institution database (N = 1538). Survival methods were used to determine the relationship among blood component ratios and inflammatory complications. RESULTS: Patients were primarily male (68%), Caucasians (89%), aged 39 ± 14 years, involved in a motor vehicle collision (53%). Eighty-six percent of patients developed an inflammatory complication; 76% developed organ failure, 27% ventilator-associated pneumonia, and 24% acute respiratory distress syndrome. Injury severity, sex, and total PRBC transfusion volume, not blood component ratio, predicted inflammatory complications. CONCLUSIONS: Increased understanding of factors associated with inflammation after trauma and PRBC transfusion is needed.

Association of Blood Component Ratio With Clinical Outcomes in Patients After Trauma and Massive Transfusion: A Systematic Review.

Component ratios that mimic whole blood may produce survival benefit in patients massively transfused after trauma; other outcomes have not been reviewed. The purpose of this review was to systematically analyze studies where clinical outcomes were compared on the basis of the component ratios administered during massive transfusion in adult patients after trauma. PubMed, CINAHL, and MEDLINE (Ovid) were searched for studies published in English between 2007 and 2015, performed at Level I or major trauma centers. Twenty-one studies were included in the analysis. We used an adapted 9-item instrument to assess bias risk. The average bias score for the studies was 2.86 ± 1.39 out of 16, indicating a low bias risk. The most common bias sources were lack of data about primary outcomes and adverse events. Those who received high ratios experienced not only greater survival benefit but also higher rates of multiple-organ failure; all other clinical outcomes findings were equivocal.