Burch J M, Ortiz V B, Richardson R J, Martin R R, Mattox K L, Jordan G L
Baylor College of Medicine, Houston, TX 77030.
Ann Surg. 1992 May;215(5):476-83; discussion 483-4. doi: 10.1097/00000658-199205000-00010.
The triad of hypothermia, acidosis, and coagulopathy in critically injured patients is a vicious cycle that, if uninterrupted, is rapidly fatal. During the past 7.5 years, 200 patients were treated with unorthodox techniques to abruptly terminate the laparotomy and break the cycle. One hundred seventy patients (85%) suffered penetrating injuries and 30 (15%) were victims of blunt trauma. The mean Revised Trauma Score, Injury Severity Score, and Trauma Index Severity Score age combination index predicted survival were 5.06%, 33.2%, and 57%, respectively. Resuscitative thoracotomies were performed in 60 (30%) patients. After major sources of hemorrhage were controlled, the following clinical and laboratory mean values were observed: red cell transfusions--22 units, core temperature--32.1 C, and pH--7.09. Techniques to abbreviate the operation included the ligation of enteric injuries in 34 patients, retained vascular clamps in 13, temporary intravascular shunts in four, packing of diffusely bleeding surfaces in 171, and the use of multiple towel clips to close only the skin of the abdominal wall in 178. Patients then were transported to the surgical intensive care unit for vigorous correction of metabolic derangements and coagulopathies. Ninety-eight patients (49%) survived to undergo planned reoperation (mean delay 48.1 hours), and 66 of 98 (67%) survived to leave the hospital. With the exception of intravascular shunts, there were survivors who were treated by each of the unorthodox techniques. Of 102 patients who died before reoperation 68 (67%) did so within 2 hours of the initial procedure. Logistic regression showed that red cell transfusion rate and pH may be helpful in determining when to consider abbreviated laparotomy. The authors conclude that patients with hypothermia, acidosis, and coagulopathy are at high risk for imminent death, and that prompt termination of laparotomy with the use of the above techniques is a rational approach to an apparently hopeless situation.
危重伤员的低体温、酸中毒和凝血功能障碍三联征是一个恶性循环，若不加以阻断，会迅速致命。在过去7.5年中，200例患者接受了非传统技术治疗，以突然终止剖腹手术并打破这个循环。170例患者（85%）为穿透伤，30例（15%）为钝性创伤。平均修正创伤评分、损伤严重度评分和创伤指数严重度评分年龄组合指数预测生存率分别为5.06%、33.2%和57%。60例（30%）患者进行了复苏性开胸手术。在控制主要出血源后，观察到以下临床和实验室平均值：红细胞输注量——22单位，核心体温——32.1℃，pH值——7.09。缩短手术时间的技术包括：34例患者结扎肠损伤，13例保留血管夹，4例使用临时血管分流术，171例对弥漫性出血创面进行填塞，178例仅用多个巾钳闭合腹壁皮肤。然后将患者转运至外科重症监护病房，积极纠正代谢紊乱和凝血功能障碍。98例患者（49%）存活下来接受了计划中的再次手术（平均延迟48.1小时），98例中的66例（67%）存活出院。除血管分流术外，每种非传统技术都有存活患者。在102例再次手术前死亡的患者中，68例（67%）在初次手术后2小时内死亡。逻辑回归分析表明，红细胞输注率和pH值可能有助于确定何时考虑缩短剖腹手术时间。作者得出结论，低体温、酸中毒和凝血功能障碍的患者面临即将死亡的高风险，使用上述技术迅速终止剖腹手术是应对明显无望情况的合理方法。
