Croce Martin A, Tolley Elizabeth A, Claridge Jeffrey A, Fabian Timothy C
Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
J Trauma. 2005 Jul;59(1):19-23; discussion 23-4. doi: 10.1097/01.ta.0000171459.21450.dc.
Prior studies have suggested that blood transfusion (Tx) is associated with infectious and respiratory complications in trauma patients. However, these studies are difficult to interpret because of small sample size, inclusion of severely injured patients in traumatic shock, and combination of a variety of unrelated low-morbidity/mortality infections, such as wound, catheter-related, and urinary tract infection as outcomes. To eliminate these confounding variables, this study evaluates the association between delayed Tx and serious, well-defined respiratory complications (ventilator-associated pneumonia [VAP] and acute respiratory distress syndrome [ARDS]) and death in a cohort of intensive care unit (ICU) admissions with less severe (Injury Severity Score [ISS] < 25) blunt trauma who received no Tx within the initial 48 hours after admission.
Patients with blunt injury and ISS < 25 admitted to the ICU over a 7-year period were identified from the registry and excluded if within 48 hours from admission they received any Tx or if they died. VAP required quantitative bronchoalveolar lavage culture (> or =10(5) colonies/mL), and ARDS required Pao2/Fio2 ratio < 200 mm Hg, *** no congestive heart failure, diffuse bilateral infiltrates, and peak airway pressure > 50 cm H2O for diagnosis. Outcomes were VAP, ARDS, and death.
Nine thousand one hundred twenty-six with blunt injury were ICU admissions, and 5,260 (58%) met study criteria (72% male). Means for age, ISS, and Glasgow Coma Scale score were 39, 12, and 14, respectively. There were 778 (15%) who received delayed Tx. Incidences of VAP, ARDS, and death were 5%, 1%, and 1%, respectively. Logistic regression analysis identified age, base excess, chest Abbreviated Injury Scale score, ISS, and any transfusion as significant predictors for VAP; chest Abbreviated Injury Scale score and transfusion as significant predictors for ARDS; and age and transfusion as significant predictors for death.
Delayed transfusion is independently associated with VAP, ARDS, and death in trauma patients regardless of injury severity. These data mandate a judicious transfusion policy after resuscitation and emphasize the need for safe and effective blood substitutes and transfusion alternatives.
先前的研究表明，输血与创伤患者的感染及呼吸系统并发症相关。然而，这些研究因样本量小、纳入创伤性休克的重伤患者以及将多种不相关的低发病率/死亡率感染（如伤口感染、导管相关感染和尿路感染）作为结果而难以解读。为消除这些混杂变量，本研究评估了延迟输血与重症监护病房（ICU）收治的一组伤情较轻（损伤严重度评分[ISS]<25）的钝性创伤患者中严重且明确的呼吸系统并发症（呼吸机相关性肺炎[VAP]和急性呼吸窘迫综合征[ARDS]）及死亡之间的关联，这些患者在入院后的最初48小时内未接受输血治疗。
从登记处识别出在7年期间入住ICU的钝性损伤且ISS<25的患者，若他们在入院后48小时内接受了任何输血治疗或已死亡，则将其排除。VAP需要定量支气管肺泡灌洗培养（≥10⁵菌落/mL），ARDS需要动脉血氧分压/吸入氧分数比<200 mmHg，***无充血性心力衰竭、双侧弥漫性浸润且气道峰压>50 cm H₂O方可诊断。结果指标为VAP、ARDS和死亡。
9126例钝性损伤患者入住ICU，5260例（58%）符合研究标准（72%为男性）。年龄、ISS和格拉斯哥昏迷量表评分平均值分别为39、12和14。778例（15%）接受了延迟输血。VAP、ARDS和死亡的发生率分别为5%、1%和1%。逻辑回归分析确定年龄、碱剩余、胸部简明损伤量表评分、ISS和任何输血为VAP的显著预测因素；胸部简明损伤量表评分和输血为ARDS的显著预测因素；年龄和输血为死亡的显著预测因素。
无论损伤严重程度如何，延迟输血与创伤患者的VAP、ARDS和死亡独立相关。这些数据要求在复苏后制定明智的输血策略，并强调需要安全有效的血液替代品和输血替代方案。
