Neff Lucas P, Cannon Jeremy W, Morrison Jonathan J, Edwards Mary J, Spinella Philip C, Borgman Matthew A
From the Department of Surgery (L.P.N.), David Grant Medical Center, Travis Air Force Base, Fairfield, California; Departments of Surgery (J.W.C., M.J.E.) and Pediatrics (M.A.B.), San Antonio Military Medical Center, Fort Sam Houston, San Antonio, Texas; Department of Surgery (L.P.N., J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland; and Department of Pediatrics (P.C.S.), Washington University School of Medicine, St. Louis, Missouri; and The Academic Department of Military Surgery and Trauma (J.J.M.), Royal Centre for Defence Medicine, Birmingham, United Kingdom.
J Trauma Acute Care Surg. 2015 Jan;78(1):22-8; discussion 28-9. doi: 10.1097/TA.0000000000000488.
Massive transfusion (MT) in pediatric patients remains poorly defined. Using the largest existing registry of transfused pediatric trauma patients, we sought a data-driven MT threshold.
The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric trauma patients (<18 years). Burns, drowning, isolated head injury, and missing Injury Severity Score (ISS) were excluded. MT was evaluated as a weight-based volume of all blood products transfused in the first 24 hours. Mortality at 24 hours and in the hospital was calculated for increasing transfusion volumes. Sensitivity and specificity curves for predicting mortality were used to identify an optimal MT threshold. Patients above and below this threshold (MT+ and MT-, respectively) were compared.
The Department of Defense Trauma Registry yielded 4,990 combat-injured pediatric trauma patients, of whom 1,113 were transfused and constituted the study cohort. Sensitivity and specificity for 24-hour and in-hospital mortality were optimal at 40.1-mL/kg and 38.6-mL/kg total blood products in the first 24 hours, respectively. With the use of a pragmatic threshold of 40 mL/kg, patients were divided into MT+ (n = 443) and MT- (n = 670). MT+ patients were more often in shock (68.1% vs. 47.0%, p < 0.001), hypothermic (13.0% vs. 3.4%, p < 0.001), coagulopathic (45.0% vs. 29.6%, p < 0.001), and thrombocytopenic (10.6% vs. 5.0%, p = 0.002) on presentation. MT+ patients had a higher ISS, more mechanical ventilator days, and longer intensive care unit and hospital stay. MT+ was independently associated with an increased 24-hour mortality (odds ratio, 2.50; 95% confidence interval, 1.28-4.88; p = 0.007) and in-hospital mortality (odds ratio, 2.58; 95% confidence interval, 1.70-3.92; p < 0.001).
Based on this large cohort of transfused combat-injured pediatric patients, a threshold of 40 mL/kg of all blood products given at any time in the first 24 hours reliably identifies critically injured children at high risk for early and in-hospital death. This evidence-based definition will provide a consistent framework for future research and protocol development in pediatric resuscitation.
Diagnostic study, level II. Prognostic/epidemiologic study, level III.
儿科患者大量输血（MT）的定义仍不明确。我们利用现有的最大规模的儿科创伤输血患者登记数据库，探寻基于数据的MT阈值。
查询2001年至2013年美国国防部创伤登记数据库中的儿科创伤患者（<18岁）。排除烧伤、溺水、单纯性头部损伤和缺失损伤严重程度评分（ISS）的患者。MT评估为患者在伤后24小时内输注的所有血液制品的基于体重的总量。计算不同输血量下患者伤后24小时及住院期间的死亡率。使用预测死亡率的敏感度和特异度曲线确定最佳MT阈值。比较高于和低于此阈值的患者（分别为MT+和MT-）。
美国国防部创伤登记数据库中有4990例战斗致伤的儿科创伤患者，其中1113例接受了输血，构成研究队列。伤后24小时及住院期间死亡率的敏感度和特异度分别在伤后24小时输注血液制品总量达到40.1 mL/kg和38.6 mL/kg时最佳。采用40 mL/kg这一实用阈值，将患者分为MT+组（n = 443）和MT-组（n = 670）。MT+组患者就诊时更常处于休克状态（68.1%对47.0%，p < 0.001）、体温过低（13.0%对3.4%，p < 0.001）、存在凝血功能障碍（45.0%对29.6%，p < 0.001）和血小板减少（10.6%对5.0%，p = 0.002）。MT+组患者ISS更高，机械通气天数更多，重症监护病房和住院时间更长。MT+独立与伤后24小时死亡率增加相关（比值比，2.50；95%置信区间，1.28 - 4.88；p = 0.007）以及住院死亡率增加相关（比值比，2.58；95%置信区间，1.70 - 3.92；p < 0.001）。
基于这一大型战斗致伤的儿科输血患者队列，伤后24小时内任何时间输注血液制品总量达到40 mL/kg这一阈值可可靠地识别出有早期和住院死亡高风险的严重受伤儿童。这一基于证据的定义将为未来儿科复苏研究和方案制定提供一个一致的框架。
诊断性研究，II级。预后/流行病学研究，III级。
