Vascular Surgery Service, San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA.
J Vasc Surg. 2012 Mar;55(3):688-92. doi: 10.1016/j.jvs.2011.10.028. Epub 2012 Jan 24.
The resuscitation of patients with ruptured abdominal aortic aneurysms (RAAAs) has not been well studied, and the potential benefit of autotransfusion (AT) is unknown. The increased use of fresh-frozen plasma (FFP) has been associated with decreased mortality rates in trauma patients and may also improve RAAA survival. We explored the influence of intraoperative AT and FFP resuscitation on mortality rates in massively transfused RAAA patients.
A single-center review of RAAA patient records from April 1989 to October 2009 was undertaken. Clinical data and outcomes were studied. Operative and anesthesia records were queried for intraoperative transfusion totals. Massive transfusion was defined as ≥10 units of red blood cells (RBCs) inclusive of AT units.
We identified 151 RAAA patients, of which 89 (60%) received a massive transfusion and comprised the study population. These 89 patients had an in-hospital mortality rate of 44%. Univariate predictors of mortality included increased age, preoperative hypotension, operative blood loss, and crystalloid, RBCs, and FFP volume. AT was used in 85 patients, with an increased ratio of AT:RBC units associated with survival. Mortality was 34% with AT:packed RBCs (PRBC) ≥1 (high AT) and 55% with AT:PRBC of <1 (low AT; P = .04). On multivariate analysis, age > 74 years (P = .03), lowest preoperative systolic blood pressure (SBP) <90 mm Hg (P = .06), blood loss >6 liters (P = .06), and low AT (P = .02) independently predicted mortality. The mean RBC:FFP ratio was similar in those that died (2.7) and in those that lived (2.9; P = .66). RBC:FFP ≤2 (high FFP) was present in 38 (43%) patients, with mortality of 49%. RBC:FFP >2 (low FFP) had 40% mortality (P = .39). RBC:FFP ratios decreased over time from 3.6 (years 1989 to 1999) to 2.2 (years 2000 to 2009; P < .001), but more liberal use of FFP was not associated with decreased mortality (47% vs 41%; P = .56). AT:PRBC ratios were stable over time (range, 1.4-1.2; P = .18).
Greater use of AT but not of FFP was associated with survival in massively transfused RAAA patients. No mortality benefit was seen with increased FFP, but few patients had high FFP transfusion ratios. Further study to identify RAAA patients at risk for massive transfusion should be undertaken and a potentially greater role for AT in RAAA resuscitation investigated.
对破裂性腹主动脉瘤（RAAA）患者的复苏尚未进行深入研究，其自体输血（AT）的潜在益处尚不清楚。新鲜冷冻血浆（FFP）的使用增加与创伤患者的死亡率降低有关，并且可能也有助于提高 RAAA 的存活率。我们探讨了术中 AT 和 FFP 复苏对大量输血的 RAAA 患者死亡率的影响。
对 1989 年 4 月至 2009 年 10 月间 RAAA 患者的病历进行了单中心回顾性分析。研究了临床数据和结果。手术和麻醉记录中查询了术中输血总量。大量输血定义为≥10 个单位的红细胞（RBCs），包括 AT 单位。
我们确定了 151 例 RAAA 患者，其中 89 例（60%）接受了大量输血，这些患者构成了研究人群。这些 89 例患者的院内死亡率为 44%。死亡率的单因素预测因素包括年龄增加、术前低血压、手术失血量以及晶体液、RBCs 和 FFP 量。85 例患者使用了 AT，与生存相关的是 AT：RBC 单位的比值增加。AT：RBC 比≥1（高 AT）的死亡率为 34%，而 AT：RBC 比<1（低 AT）的死亡率为 55%（P=0.04）。多因素分析显示，年龄>74 岁（P=0.03）、术前最低收缩压（SBP）<90mmHg（P=0.06）、失血量>6 升（P=0.06）和低 AT（P=0.02）是独立的死亡预测因素。死亡患者（2.7）和存活患者（2.9；P=0.66）的 RBC：FFP 比值相似。RBC：FFP≤2（高 FFP）见于 38 例（43%）患者，死亡率为 49%。RBC：FFP>2（低 FFP）的死亡率为 40%（P=0.39）。RBC：FFP 比值随时间从 3.6（1989 年至 1999 年）降至 2.2（2000 年至 2009 年；P<0.001），但 FFP 的更自由使用并未降低死亡率（47%与 41%；P=0.56）。AT：RBC 比值随时间保持稳定（范围为 1.4-1.2；P=0.18）。
在大量输血的 RAAA 患者中，更多地使用 AT 而不是 FFP 与生存相关。FFP 输注增加并未带来死亡率的降低，但接受高 FFP 输注的患者比例很少。应进一步研究确定易发生大量输血的 RAAA 患者，并进一步研究 AT 在 RAAA 复苏中的潜在作用。
