Holcomb John B, Wade Charles E, Michalek Joel E, Chisholm Gary B, Zarzabal Lee Ann, Schreiber Martin A, Gonzalez Ernest A, Pomper Gregory J, Perkins Jeremy G, Spinella Phillip C, Williams Kari L, Park Myung S
United States Army Institute of Surgical Research, Ft Sam Houston, TX 78234, USA.
Ann Surg. 2008 Sep;248(3):447-58. doi: 10.1097/SLA.0b013e318185a9ad.
To determine the effect of blood component ratios in massive transfusion (MT), we hypothesized that increased use of plasma and platelet to red blood cell (RBC) ratios would result in decreased early hemorrhagic death and this benefit would be sustained over the ensuing hospitalization.
Civilian guidelines for massive transfusion (MT > or =10 units of RBC in 24 hours) have typically recommend a 1:3 ratio of plasma:RBC, whereas optimal platelet:RBC ratios are unknown. Conversely, military data shows that a plasma:RBC ratio approaching 1:1 improves long term outcomes in MT combat casualties. There is little consensus on optimal platelet transfusions in either civilian or military practice. At present, the optimal combinations of plasma, platelet, and RBCs for MT in civilian patients is unclear.
Records of 467 MT trauma patients transported from the scene to 16 level 1 trauma centers between July 2005 and June 2006 were reviewed. One patient who died within 30 minutes of admission was excluded. Based on high and low plasma and platelet to RBC ratios, 4 groups were analyzed.
Among 466 MT patients, survival varied by center from 41% to 74%. Mean injury severity score varied by center from 22 to 40; the average of the center means was 33. The plasma:RBC ratio ranged from 0 to 2.89 (mean +/- SD: 0.56 +/- 0.35) and the platelets:RBC ratio ranged from 0 to 2.5 (0.55 +/- 0.50). Plasma and platelet to RBC ratios and injury severity score were predictors of death at 6 hours, 24 hours, and 30 days in multivariate logistic models. Thirty-day survival was increased in patients with high plasma:RBC ratio (> or =1:2) relative to those with low plasma:RBC ratio (<1:2) (low: 40.4% vs. high: 59.6%, P < 0.01). Similarly, 30-day survival was increased in patients with high platelet:RBC ratio (> or =1:2) relative to those with low platelet:RBC ratio (<1:2) (low: 40.1% vs. high: 59.9%, P < 0.01). The combination of high plasma and high platelet to RBC ratios were associated with decreased truncal hemorrhage, increased 6-hour, 24-hour, and 30-day survival, and increased intensive care unit, ventilator, and hospital-free days (P < 0.05), with no change in multiple organ failure deaths. Statistical modeling indicated that a clinical guideline with mean plasma:RBC ratio equal to 1:1 would encompass 98% of patients within the optimal 1:2 ratio.
Current transfusion practices and survival rates of MT patients vary widely among trauma centers. Conventional MT guidelines may underestimate the optimal plasma and platelet to RBC ratios. Survival in civilian MT patients is associated with increased plasma and platelet ratios. Massive transfusion practice guidelines should aim for a 1:1:1 ratio of plasma:platelets:RBCs.
为确定大量输血（MT）时血液成分比例的影响，我们假设增加血浆及血小板与红细胞（RBC）的比例会降低早期出血性死亡风险，且这一益处会在后续住院期间持续存在。
平民大量输血（24小时内输注≥10单位RBC）的指南通常推荐血浆与RBC的比例为1:3，而最佳血小板与RBC的比例尚不清楚。相反，军方数据显示，血浆与RBC比例接近1:1可改善MT战斗伤员的长期预后。在平民或军事实践中，关于最佳血小板输注几乎没有共识。目前，尚不清楚平民患者MT时血浆、血小板和RBC的最佳组合。
回顾了2005年7月至2006年6月期间从现场转运至16家一级创伤中心的467例MT创伤患者的记录。排除1例入院后30分钟内死亡的患者。根据血浆和血小板与RBC的高、低比例，分析4组患者。
在466例MT患者中，各中心的生存率从41%到74%不等。平均损伤严重程度评分各中心从22到40不等；各中心平均值的平均数为33。血浆与RBC的比例范围为0至2.89（均值±标准差：0.56±0.35），血小板与RBC的比例范围为0至2. (0.55±0.50)。在多因素逻辑模型中，血浆和血小板与RBC的比例以及损伤严重程度评分是6小时、24小时和30天死亡的预测因素。与血浆与RBC比例低（<1:2）的患者相比，血浆与RBC比例高（≥1:2）的患者30天生存率更高（低：40.4%对高：59.6%，P<0.01）。同样，与血小板与RBC比例低（<1:2）的患者相比，血小板与RBC比例高（≥1:2）的患者30天生存率更高（低：40.1%对高：59.9%，P<0.01）。血浆和血小板与RBC比例均高与躯干出血减少、6小时、24小时和30天生存率增加以及重症监护病房、呼吸机使用天数和无住院天数增加相关（P<0.05），多器官功能衰竭死亡无变化。统计模型表明，血浆与RBC平均比例等于1:1的临床指南将涵盖最佳1:2比例内98%的患者。
目前各创伤中心MT患者的输血实践和生存率差异很大。传统的MT指南可能低估了最佳血浆和血小板与RBC的比例。平民MT患者的生存与血浆和血小板比例增加有关。大量输血实践指南应旨在实现血浆:血小板:RBC为1:1:1的比例。
