Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
J Trauma Acute Care Surg. 2013 Jul;75(1):32-6; discussion 36. doi: 10.1097/TA.0b013e318294672d.
An unresolved concern regarding resuscitation in the setting of massive hemorrhage is potential lung injury from the transfusion of relatively more plasma-rich components. However, the association between plasma-to-packed red blood cell (PRBC) ratio and subsequent pulmonary dysfunction remains unclear. The purpose of this study was to evaluate the impact of plasma/PRBC on PaO2-to-FIO2 (P/F) ratio in the setting of massive transfusion (MT).
During a 5.5-year period, prospective data were collected on trauma patients who underwent MT, defined as 10 or more units of PRBC transfusion by completion of hemorrhage control. Deaths within 48 hours of arrival were excluded. Acute lung injury (ALI) and adult respiratory distress syndrome (ARDS) were defined as P/F ratio of less than 300 and less than 200 at 48 hours, respectively. Stepwise multiple regression analysis was performed to determine variables significantly associated with P/F ratio.
A total of 199 patients met inclusion criteria; 159 (80%) developed ALI, and 105 (53%) developed ARDS. ALI and ARDS were both associated with subsequent mortality: ARDS at 24% versus no ARDS at 10% (p < 0.05) and ALI at 21% versus no ALI at 2.5% (p < 0.05). Paradoxically, patients with P/F ratio of 300 or greater were found to have received more plasma (5.6 U vs. 4.3 U, p < 0.05) and higher plasma-to-PRBC ratio (1:2 vs. 1:3, p < 0.05) at completion of hemorrhage control. Stepwise multiple regression analysis, however, identified age (p < 0.001) and chest Abbreviated Injury Scale (AIS) score (p = 0.04), but not plasma/PRBC (p = 0.10), to be independent determinants of P/F ratio at 48 hours.
In this cohort of MT patients who survived beyond the first 48 hours, pulmonary dysfunction developed in the majority and was associated with a 10-fold higher risk of subsequent death. However, plasma-to-RBC ratio achieved during hemorrhage control had neither a positive nor a negative impact on subsequent P/F ratio. In fact, only unalterable patient factors including age and severity of thoracic injury were associated with subsequent P/F ratio.
Prognostic study, level III.
大量出血时复苏的一个悬而未决的问题是，由于输注相对更多富含血浆的成分，可能会导致肺部损伤。然而，血浆与浓缩红细胞（PRBC）比值与随后的肺功能障碍之间的关系仍不清楚。本研究的目的是评估大量输血（MT）中血浆/PRBC 对 PaO2 与 FIO2（P/F）比值的影响。
在 5.5 年期间，前瞻性收集了接受 MT 的创伤患者的数据，定义为控制出血完成后输注 10 个或更多 PRBC 单位。排除入院后 48 小时内死亡的患者。急性肺损伤（ALI）和成人呼吸窘迫综合征（ARDS）分别定义为 48 小时时 P/F 比值<300 和<200。采用逐步多元回归分析确定与 P/F 比值显著相关的变量。
共纳入 199 例患者；159 例（80%）发生 ALI，105 例（53%）发生 ARDS。ALI 和 ARDS 均与随后的死亡率相关：ARDS 为 24%，无 ARDS 为 10%（p<0.05）；ALI 为 21%，无 ALI 为 2.5%（p<0.05）。矛盾的是，发现 P/F 比值为 300 或更高的患者在控制出血完成时接受了更多的血浆（5.6 U 比 4.3 U，p<0.05）和更高的血浆与 PRBC 比值（1:2 比 1:3，p<0.05）。然而，逐步多元回归分析确定年龄（p<0.001）和胸部损伤简略损伤评分（AIS）（p=0.04），而不是血浆/PRBC（p=0.10），是 48 小时时 P/F 比值的独立决定因素。
在本队列中，存活超过 48 小时的 MT 患者中，大多数患者出现肺功能障碍，且随后死亡的风险增加 10 倍。然而，在控制出血期间达到的血浆与 RBC 比值对随后的 P/F 比值既没有积极影响也没有消极影响。事实上，只有不可改变的患者因素，包括年龄和胸部损伤的严重程度，与随后的 P/F 比值相关。
预后研究，III 级。
