在一家平民创伤中心实施源自军事的损伤控制性复苏策略可减少大量输血患者的急性缺氧。
Implementation of a military-derived damage-control resuscitation strategy in a civilian trauma center decreases acute hypoxia in massively transfused patients.
机构信息
Institute for Military Medicine, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA.
出版信息
J Trauma Acute Care Surg. 2013 Aug;75(2 Suppl 2):S221-7. doi: 10.1097/TA.0b013e318299d59b.
BACKGROUND
Recent military experience supports a paradigm shift in shock resuscitation to damage-control resuscitation (DCR), which emphasizes a plasma-rich and crystalloid-poor approach to resuscitation. The effect of DCR on hypoxia after massive transfusion is unknown. We hypothesized that implementation of a military-derived DCR strategy in a civilian setting would lead to decreased acute hypoxia.
METHODS
A DCR strategy was implemented in 2007. We retrospectively reviewed patients receiving trauma surgeon operative intervention and 10 or more units of packed red blood cells (pRBCs) within 24 hours of injury at an adult Level I trauma center from 2001 to 2010. Demographic data, blood requirements, and PaO₂/FIO₂ ratios were analyzed. To evaluate evolving resuscitation strategies, we fit linear trend models to continuous variables and tested their slopes for statistical significance.
RESULTS
Two hundred sixteen patients met the study criteria, with a mean age of 35 ± 1.1 years and Injury Severity Score (ISS) of 31 ± 9.0. Of the patients, 80% were male, and 52% sustained penetrating injuries. Overall mortality was 32%. Overall mean pRBC and fresh frozen plasma (FFP) units infused in 24 hours were 23.2 ± 1.1 and 18.6 ± 1.1, respectively. Trends for patient age, sex, mechanism of injury, ISS, highest positive end-expiratory pressure, and mean total pRBC transfused over 24 hours were not statistically different from zero. An increasing trend in FFP and platelets transfused during the first 24 hours (p < 0.0001, p = 0.04, respectively) and a decrease in the pRBC/FFP ratio (p < 0.0001) were found. The amount of crystalloid infused during the initial 24 hours decreased with time (p < 0.0001). The lowest PaO₂/FIO₂ ratio recorded during the initial 24 hours increased during the study period (p = 0.01), indicating a statistically significant reduction in hypoxia.
CONCLUSION
A military-derived DCR strategy can be implemented in the civilian setting. DCR led to significant increases in FFP transfusion, decreases in crystalloid use, and acute hypoxia.
背景
最近的军事经验支持对休克复苏进行范式转变，转向损伤控制性复苏（DCR），这强调了复苏时采用富含血浆和低晶液体的方法。DCR 对大量输血后缺氧的影响尚不清楚。我们假设，在民用环境中实施源自军事的 DCR 策略将导致急性缺氧减少。
方法
2007 年实施了 DCR 策略。我们回顾性分析了 2001 年至 2010 年在成人一级创伤中心接受创伤外科手术干预和 24 小时内接受 10 个或更多单位浓缩红细胞（pRBC）的患者。分析了人口统计学数据、血液需求和 PaO₂/FIO₂ 比值。为了评估不断发展的复苏策略，我们对连续变量进行线性趋势模型拟合，并测试其斜率是否具有统计学意义。
结果
216 名患者符合研究标准，平均年龄为 35 ± 1.1 岁，损伤严重程度评分（ISS）为 31 ± 9.0。患者中 80%为男性，52%为穿透性损伤。总体死亡率为 32%。总体平均 pRBC 和新鲜冷冻血浆（FFP）在 24 小时内输注的单位分别为 23.2 ± 1.1 和 18.6 ± 1.1。患者年龄、性别、损伤机制、ISS、最高呼气末正压和 24 小时内平均总 pRBC 输注的趋势与零值没有统计学差异。在最初的 24 小时内，FFP 和血小板的输注呈上升趋势（p < 0.0001，p = 0.04），pRBC/FFP 比值下降（p < 0.0001）。最初的 24 小时内输注的晶液体量随时间减少（p < 0.0001）。最初的 24 小时内记录的最低 PaO₂/FIO₂ 比值在研究期间增加（p = 0.01），表明缺氧程度显著降低。
结论
源自军事的 DCR 策略可以在民用环境中实施。DCR 导致 FFP 输注显著增加，晶液体用量减少，急性缺氧减少。
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