Division of Trauma and Surgical Critical Care, Department of Surgery, Keck School of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, CA 90033, USA.
J Am Coll Surg. 2013 Feb;216(2):290-7. doi: 10.1016/j.jamcollsurg.2012.10.017. Epub 2012 Dec 2.
For critically injured patients requiring a massive transfusion, the optimal plasma fibrinogen level is unknown. The purpose of this study was to examine the impact of the fibrinogen level on mortality. We hypothesized that decreasing fibrinogen levels are associated with worse outcomes.
All patients undergoing a massive transfusion from January 2000 through December 2011 were retrospectively identified. Those with a fibrinogen level measured on admission to the surgical ICU were analyzed according to their fibrinogen level (normal [≥180 mg/dL], abnormal [≥101 to <180 mg/dL], and critical [≤100 mg/dL]). Primary outcome was death. Multivariate analysis evaluated the impact of fibrinogen on survival.
There were 260 patients who met inclusion criteria. Ninety-two patients had normal admission fibrinogen levels, 114 had abnormal levels, and 54 patients had critical levels. Patients with a critical fibrinogen level had significantly higher mortality at 24 hours compared with patients with abnormal (31.5% vs 5.3%; adj. p < 0.001) and normal fibrinogen levels (31.5% vs 4.3%; adjusted p < 0.001). Patients with a critical fibrinogen level had significantly higher in-hospital mortality compared with patients with abnormal (51.9% vs 25.4%; adjusted p = 0.013) and normal fibrinogen levels (51.9% vs 18.5%; adjusted p < 0.001). A critical fibrinogen level was the most important independent predictor of mortality (p = 0.012).
For patients undergoing a massive transfusion after injury, as the fibrinogen level increased, a stepwise improvement in survival was noted. A fibrinogen level ≤100 mg/dL was a strong independent risk factor for death. The impact of an aggressive fibrinogen replacement strategy using readily available products warrants further prospective evaluation.
对于需要大量输血的严重创伤患者，最佳血浆纤维蛋白原水平尚不清楚。本研究旨在探讨纤维蛋白原水平对死亡率的影响。我们假设纤维蛋白原水平降低与预后不良有关。
回顾性分析 2000 年 1 月至 2011 年 12 月期间所有接受大量输血的患者。根据纤维蛋白原水平（正常[≥180mg/dL]、异常[≥101 至<180mg/dL]和临界[≤100mg/dL]）对入院时测量纤维蛋白原的外科 ICU 患者进行分析。主要结局为死亡。多变量分析评估纤维蛋白原对生存的影响。
符合纳入标准的患者有 260 例。92 例患者入院时纤维蛋白原水平正常，114 例患者纤维蛋白原水平异常，54 例患者纤维蛋白原水平临界。与纤维蛋白原水平异常的患者（31.5%比 5.3%；调整后 p<0.001）和正常纤维蛋白原水平的患者（31.5%比 4.3%；调整后 p<0.001）相比，纤维蛋白原水平临界的患者 24 小时死亡率显著更高。与纤维蛋白原水平异常的患者（51.9%比 25.4%；调整后 p=0.013）和正常纤维蛋白原水平的患者（51.9%比 18.5%；调整后 p<0.001）相比，纤维蛋白原水平临界的患者院内死亡率显著更高。纤维蛋白原水平临界是死亡率的最重要独立预测因素（p=0.012）。
对于创伤后接受大量输血的患者，随着纤维蛋白原水平的升高，生存率逐渐提高。纤维蛋白原水平≤100mg/dL 是死亡的强烈独立危险因素。使用现有产品积极进行纤维蛋白原替代治疗的影响值得进一步前瞻性评估。
