损伤控制血液学：创伤性失血方案对生存率和血液制品使用的影响。

Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization.

作者信息

Cotton Bryan A, Gunter Oliver L, Isbell James, Au Brigham K, Robertson Amy M, Morris John A, St Jacques Paul, Young Pampee P

机构信息

Departments of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

出版信息

J Trauma. 2008 May;64(5):1177-82; discussion 1182-3. doi: 10.1097/TA.0b013e31816c5c80.

DOI:10.1097/TA.0b013e31816c5c80

PMID:18469638

Abstract

BACKGROUND

The importance of early and aggressive management of trauma- related coagulopathy remains poorly understood. We hypothesized that a trauma exsanguination protocol (TEP) that systematically provides specified numbers and types of blood components immediately upon initiation of resuscitation would improve survival and reduce overall blood product consumption among the most severely injured patients.

METHODS

We recently implemented a TEP, which involves the immediate and continued release of blood products from the blood bank in a predefined ratio of 10 units of packed red blood cells (PRBC) to 4 units of fresh frozen plasma to 2 units of platelets. All TEP activations from February 1, 2006 to July 31, 2007 were retrospectively evaluated. A comparison cohort (pre-TEP) was selected from all trauma admissions between August 1, 2004 and January 31, 2006 that (1) underwent immediate surgery by the trauma team and (2) received greater than 10 units of PRBC in the first 24 hours. Multivariable analysis was performed to compare mortality and overall blood product consumption between the two groups.

RESULTS

Two hundred eleven patients met inclusion criteria (117 pre-TEP, 94 TEP). Age, sex, and Injury Severity Score were similar between the groups, whereas physiologic severity (by weighted Revised Trauma Score) and predicted survival (by trauma-related Injury Severity Score, TRISS) were worse in the TEP group (p values of 0.037 and 0.028, respectively). After controlling for age, sex, mechanism of injury, TRISS and 24-hour blood product usage, there was a 74% reduction in the odds of mortality among patients in the TEP group (p = 0.001). Overall blood product consumption adjusted for age, sex, mechanism of injury, and TRISS was also significantly reduced in the TEP group (p = 0.015).

CONCLUSIONS

We have demonstrated that an exsanguination protocol, delivered in an aggressive and predefined manner, significantly reduces the odds of mortality as well as overall blood product consumption.

摘要

背景

创伤相关凝血病早期积极治疗的重要性仍未得到充分理解。我们假设，一种创伤性失血方案（TEP），即在复苏开始时系统地提供特定数量和类型的血液成分，将提高最严重受伤患者的生存率并减少总体血液制品消耗。

方法

我们最近实施了一种TEP，该方案涉及血库按10单位浓缩红细胞（PRBC）比4单位新鲜冰冻血浆比2单位血小板的预定比例立即并持续发放血液制品。对2006年2月1日至2007年7月31日期间所有激活TEP的情况进行回顾性评估。从2004年8月1日至2006年1月31日期间所有创伤入院患者中选择一个对照队列（TEP前），这些患者（1）由创伤团队立即进行手术，（2）在最初24小时内接受超过10单位的PRBC。进行多变量分析以比较两组之间的死亡率和总体血液制品消耗。

结果

211名患者符合纳入标准（117名TEP前，94名TEP）。两组之间的年龄、性别和损伤严重度评分相似，而TEP组的生理严重度（通过加权修订创伤评分）和预测生存率（通过创伤相关损伤严重度评分，TRISS）更差（p值分别为0.037和0.028）。在控制年龄、性别、损伤机制、TRISS和24小时血液制品使用情况后，TEP组患者的死亡几率降低了74%（p = 0.001）。在调整年龄、性别、损伤机制和TRISS后，TEP组的总体血液制品消耗也显著减少（p = 0.015）。