Holcomb John B, Zarzabal Lee A, Michalek Joel E, Kozar Rosemary A, Spinella Phillip C, Perkins Jeremy G, Matijevic Nena, Dong Jing-Fei, Pati Shibani, Wade Charles E, Holcomb J B, Wade C E, Cotton B A, Kozar R A, Brasel K J, Vercruysse G A, MacLeod J B, Dutton R P, Hess J R, Duchesne J C, McSwain N E, Muskat P C, Johannigamn J A, Cryer H M, Tillou A, Cohen M J, Pittet J F, Knudson P, DeMoya M A, Schreiber M A, Tieu B H, Brundage S I, Napolitano L M, Brunsvold M E, Sihler K C, Beilman G J, Peitzman A B, Zenati M S, Sperry J L, Alarcon L H, Croce M A, Minei J P, Steward R M, Cohn S M, Michalek J E, Bulger E M, Nunez T C, Ivatury R R, Meredith J W, Miller P R, Pomper G J, Marin B
Division of Acute Care Surgery, Center for Translational Injury Research, University of Texas Health Sciences Center, Houston, Texas 77030, USA.
J Trauma. 2011 Aug;71(2 Suppl 3):S318-28. doi: 10.1097/TA.0b013e318227edbb.
Several recent military and civilian trauma studies demonstrate that improved outcomes are associated with early and increased use of plasma-based resuscitation strategies. However, outcomes associated with platelet transfusions are poorly characterized. We hypothesized that increased platelet:red blood cells (RBC) ratios would decrease hemorrhagic death and improve survival after massive transfusion (MT).
A transfusion database of patients transported from the scene to 22 Level I Trauma Centers over 12 months in 2005 to 2006 was reviewed. MT was defined as receiving ≥ 10 RBC units within 24 hours of admission. To mitigate survival bias, 25 patients who died within 60 minutes of arrival were excluded from analysis. Six random donor platelet units were considered equal to a single apheresis platelet unit. Admission and outcome data associated with the low (>1:20), medium (1:2), and high (1:1) platelet:RBC ratios were examined. These groups were based on the median value of the tertiles for the ratio of platelets:RBC units.
Two thousand three hundred twelve patients received at least one unit of blood and 643 received an MT. Admission vital signs, INR, temperature, pH, Glasgow Coma Scale, Injury Severity Score, and age were similar between platelet ratio groups. The average admission platelet counts were lower in the patients who received the high platelet:RBC ratio versus the low ratio (192 vs. 216, p = 0.03). Patients who received MT were severely injured, with a mean (± standard deviation) Injury Severity Score of 33 ± 16 and received 22 ± 15 RBCs and 11 ± 14 platelets within 24 hours of injury. Increased platelet ratios were associated with improved survival at 24 hours and 30 days (p < 0.001 for both). Truncal hemorrhage as a cause of death was decreased (low: 67%, medium: 60%, high: 47%, p = 0.04). Multiple organ failure mortality was increased (low: 7%, medium: 16%, high: 27%, p = 0.003), but overall 30-day survival was improved (low: 52%, medium: 57%, high: 70%) in the high ratio group (medium vs. high: p = 0.008; low vs. high: p = 0.007).
Similar to recently published military data, transfusion of platelet:RBC ratios of 1:1 was associated with improved early and late survival, decreased hemorrhagic death and a concomitant increase in multiple organ failure-related mortality. Based on this large retrospective study, increased and early use of platelets may be justified, pending the results of prospective randomized transfusion data.
最近的几项军事和民用创伤研究表明，早期增加使用基于血浆的复苏策略与改善预后相关。然而，与血小板输注相关的预后特征尚不明确。我们假设增加血小板与红细胞（RBC）的比例会降低出血性死亡，并改善大量输血（MT）后的生存率。
回顾了2005年至2006年12个月内从现场转运至22家一级创伤中心的患者输血数据库。MT定义为入院后24小时内接受≥10个RBC单位。为减轻生存偏差，将到达后60分钟内死亡的25例患者排除在分析之外。六个随机供体血小板单位被视为等同于一个单采血小板单位。检查了与低（>1:20）、中（1:2）和高（1:1）血小板与RBC比例相关的入院和预后数据。这些组基于血小板与RBC单位比例三分位数的中位数。
2312例患者接受了至少一个单位的血液，643例接受了MT。血小板比例组之间的入院生命体征、国际标准化比值（INR）、体温、pH值、格拉斯哥昏迷量表、损伤严重程度评分和年龄相似。接受高血小板与RBC比例的患者入院时平均血小板计数低于低比例患者（192对216，p = 0.03）。接受MT的患者伤势严重，平均（±标准差）损伤严重程度评分为33±16，受伤后24小时内接受22±15个RBC和11±14个血小板。血小板比例增加与24小时和30天生存率提高相关（两者p < 0.001）。作为死亡原因的躯干出血减少（低：67%，中：60%，高：47%，p = 0.04）。多器官功能衰竭死亡率增加（低：7%，中：16%，高：27%，p = 0.003），但高比例组的总体30天生存率提高（低：52%，中：57%，高：70%）（中与高：p = 0.008；低与高：p = 0.007）。
与最近发表的军事数据相似，血小板与RBC比例为1:1的输血与早期和晚期生存率提高、出血性死亡减少以及多器官功能衰竭相关死亡率的相应增加相关。基于这项大型回顾性研究，在获得前瞻性随机输血数据结果之前，增加和早期使用血小板可能是合理的。
