1Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Emory University, Atlanta, GA. 2Division of Pulmonary/Critical Care Medicine, Johns Hopkins University, Baltimore, MD. 3Division of Pulmonary and Critical Care Medicine, Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD. 4Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. 5Department of Pathology, Johns Hopkins University, Baltimore, MD. 6Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, Baltimore, MD.
Crit Care Med. 2013 Oct;41(10):2344-53. doi: 10.1097/CCM.0b013e31828e9a49.
Increasing evidence, including publication of the Transfusion Requirements in Critical Care trial in 1999, supports a lower hemoglobin threshold for RBC transfusion in ICU patients. However, little is known regarding the influence of this evidence on clinical practice over time in a large population-based cohort.
Retrospective population-based cohort study.
Thirty-five Maryland hospitals.
Seventy-three thousand three hundred eighty-five nonsurgical adults with an ICU stay greater than 1 day between 1994 and 2007.
None.
The unadjusted odds of patients receiving an RBC transfusion increased from 7.9% during the pre-Transfusion Requirements in Critical Care baseline period (1994-1998) to 14.7% during the post-Transfusion Requirements in Critical Care period (1999-2007). A logistic regression model, including 40 relevant patient and hospital characteristics, compared the annual trend in the adjusted odds of RBC transfusion during the pre- versus post-Transfusion Requirements in Critical Care periods. During the pre-Transfusion Requirements in Critical Care period, the trend in the adjusted odds of RBC transfusion did not differ between hospitals averaging>200 annual ICU discharges and hospitals averaging≤200 annual ICU discharges (odds ratio, 1.07 [95% CI, 1.01-1.13] annually and 1.03 [95% CI, 0.99-1.07] annually, respectively; p=0.401). However, during the post-Transfusion Requirements in Critical Care period, the adjusted odds of RBC transfusion decreased over time in higher ICU volume hospitals (odds ratio, 0.96 [95% CI, 0.93-0.98] annually) but continued to increase in lower ICU volume hospitals (odds ratio, 1.10 [95% CI, 1.08-1.13] annually), p<0.001.
In this population-based cohort of ICU patients, the unadjusted odds of RBC transfusion increased in both higher and lower ICU volume hospitals both before and after Transfusion Requirements in Critical Care publication. After adjusting for relevant characteristics, the odds continued to increase in lower ICU volume hospitals in the post-Transfusion Requirements in Critical Care period, but it decreased in higher ICU volume hospitals. This suggests that evidence supporting restrictive RBC transfusion thresholds may not be uniformly translated into practice in different hospital settings.
越来越多的证据表明，包括 1999 年发表的《危重病患者输血需求研究》，支持 ICU 患者的 RBC 输血更低的血红蛋白阈值。然而，在一个大型基于人群的队列中，关于随着时间的推移，这一证据对临床实践的影响，人们知之甚少。
回顾性基于人群的队列研究。
马里兰州的 35 家医院。
1994 年至 2007 年间，73385 名非手术性 ICU 住院时间超过 1 天的成年人。
无。
未调整的 RBC 输血患者接受输血的几率从输血需求研究的基线期（1994-1998 年）的 7.9%增加到输血需求研究后的时期（1999-2007 年）的 14.7%。一个包括 40 个相关患者和医院特征的逻辑回归模型，比较了输血需求研究前后调整后的 RBC 输血几率的年度趋势。在输血需求研究之前的时期，每年在 ICU 出院人数平均>200 人和 ICU 出院人数平均≤200 人的医院之间，RBC 输血调整后几率的趋势没有差异（比值比，1.07[95%CI，1.01-1.13]和 1.03[95%CI，0.99-1.07]；p=0.401）。然而，在输血需求研究之后的时期，RBC 输血的调整后几率在 ICU 容量较高的医院随时间下降（比值比，0.96[95%CI，0.93-0.98]每年），但在 ICU 容量较低的医院继续增加（比值比，1.10[95%CI，1.08-1.13]每年），p<0.001。
在这个 ICU 患者的基于人群的队列中，在输血需求研究发表前后，较高和较低 ICU 容量的医院的 RBC 输血几率均未调整。在调整了相关特征后，在输血需求研究之后的时期，较低 ICU 容量的医院的几率继续增加，但在较高 ICU 容量的医院则下降。这表明，支持限制性 RBC 输血阈值的证据可能并没有在不同的医院环境中得到统一的转化。
