Nunez Timothy C, Young Pampee P, Holcomb John B, Cotton Bryan A
Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas, USA.
J Trauma. 2010 Jun;68(6):1498-505. doi: 10.1097/TA.0b013e3181d3cc25.
The majority of trauma patients (>90%) do not require any blood product transfusion and their mortality is <1%. However, 3% to 5% of civilian trauma patients will receive a massive transfusion (MT), defined as >10 units of packed red blood cells (PRBC) in 24 hours. In addition, more than 25% of these patients will arrive to emergency departments with evidence of trauma-associated coagulopathy. With this combination of massive blood loss and coagulopathy, it has become increasingly more common to transfuse early the trauma patients and with a combination of PRBC, plasma, and platelets. Given the inherent uncertainties common early in the care of patients with severe injuries, the efficient administration of massive amounts of PRBC and clotting factors tends to work best in a predefined, protocol driven system. Our purpose here is to (1) define the problem of massive hemorrhage and coagulopathy in the trauma patient, (2) identify which group of patients this type of protocol should be applied, (3) describe the extensive coordination required to implement this multispecialty MT protocol, (4) explain in detail how the MT was developed and implemented, and (5) emphasize the need for a robust performance improvement or quality improvement process to monitor the implementation of such a protocol and to help identify problems and deliver feedback in a "real-time" fashion. The successful implementation of such a complex process can only be accomplished in a multispecialty setting. Input and representation from departments of Trauma, Critical Care, Anesthesiology, Transfusion Medicine, and Emergency Medicine are necessary to successfully formulate (and implement) such a protocol. Once a protocol has been agreed upon, education of the entire nursing and physician staff is equally essential to the success of this effort. Once implemented, this process may lead to improved clinical outcomes and decreased overall blood utilization with extremely small wastage of vital blood products.
大多数创伤患者（>90%）不需要输血，其死亡率<1%。然而，3%至5%的 civilian 创伤患者会接受大量输血（MT），定义为24小时内输注超过10单位的浓缩红细胞（PRBC）。此外，超过25%的此类患者会在到达急诊科时就有创伤相关凝血病的证据。鉴于大量失血和凝血病同时存在，早期对创伤患者进行输血并联合使用PRBC、血浆和血小板的情况越来越普遍。鉴于严重受伤患者早期护理中常见的内在不确定性，在预先定义的、协议驱动的系统中，高效管理大量PRBC和凝血因子往往效果最佳。我们在此的目的是：（1）界定创伤患者大量出血和凝血病的问题；（2）确定应应用此类协议的患者群体；（3）描述实施这种多专业MT协议所需的广泛协调；（4）详细解释MT是如何制定和实施的；（5）强调需要一个强大的性能改进或质量改进过程来监测此类协议的实施，并以“实时”方式帮助识别问题和提供反馈。这样一个复杂过程的成功实施只能在多专业环境中完成。创伤科、重症监护科、麻醉科、输血医学科和急诊科的投入和参与对于成功制定（和实施）此类协议是必要的。一旦协议达成，对全体护理和医师人员进行教育对于这项工作的成功同样至关重要。一旦实施，这个过程可能会改善临床结果，减少总体血液使用量，同时极小化重要血液制品的浪费。
