2002年至2012年在阿富汗和伊拉克需要输血的小儿创伤患者中平衡血液成分复苏和晶体液输注的效果
The effects of balanced blood component resuscitation and crystalloid administration in pediatric trauma patients requiring transfusion in Afghanistan and Iraq 2002 to 2012.
作者信息
Edwards Mary J, Lustik Michael B, Clark Margaret E, Creamer Kevin M, Tuggle David
机构信息
From the Department of Surgery (M.J.E.), San Antonio Military Medical Center, San Antonio; and Department of Trauma (D.T.), UT Southwestern, Dell Children's Medical Center, Austin, Texas; Department of Clinical Investigation (M.B.L.) and Department of Surgery (M.E.C.), Tripler Army Medical Center, Honolulu, Hawaii; Hospitalist Division (K.M.C.), Children's National Medical Center, Washington, District of Columbia.
出版信息
J Trauma Acute Care Surg. 2015 Feb;78(2):330-5. doi: 10.1097/TA.0000000000000469.
BACKGROUND
Component balanced resuscitation and avoidance of crystalloids in traumatically injured adults requiring massive transfusion are beneficial. Evidence for children is lacking.
METHODS
After institutional review board approval was obtained, the Department of Defense Trauma Database identified 1,311 injured children 14 years or younger requiring transfusion after an injury and admitted to a deployed US military hospital from 2002 to 2012. Logistic regression determined risk factors for high-volume (≥40 mL/kg) or massive (≥70 mL/kg) transfusions. The effects of crystalloid and balanced component resuscitation in the first 24 hours were assessed.
RESULTS
Nine hundred seven patients had recorded data sufficient for analysis. Two hundred twenty-four children received high-volume transfusion, and 77 received massive transfusions. Mortality was significantly higher for massive transfusions and high-volume transfusions than others (25% vs. 10% and 19% vs. 9%, respectively). Age of less than 4 years, penetrating injury, and Injury Severity Score (ISS) greater than 15 were associated with high-volume transfusions; an ISS greater than 15 and penetrating injury were associated with massive transfusions. Increased crystalloid administration showed a significant positive association with hospital days and intensive care unit days for both massive and high-volume transfusions, as well as a significant positive association with increased ventilator days in patients with high-volume transfusions. Balanced component resuscitation was not associated with improved measured outcomes and was independently associated with a higher mortality when all transfused patients were considered.
CONCLUSION
In this cohort, heavy reliance on crystalloid for resuscitation had an adverse effect on outcomes. Balanced component resuscitation did not improve outcomes and was associated with higher mortality when all transfused patients were considered. Further study is needed regarding efficacy and clinical triggers for the implementation of massive transfusion in children.
LEVEL OF EVIDENCE
Prognostic study, level IV.
背景
对于需要大量输血的创伤成年患者，成分平衡复苏及避免使用晶体液是有益的。但儿童方面的证据尚缺。
方法
在获得机构审查委员会批准后，国防部创伤数据库确定了2002年至2012年间14岁及以下受伤后需要输血并入住美国部署在海外军事医院的1311名儿童。逻辑回归分析确定了大量（≥40 mL/kg）或超大剂量（≥70 mL/kg）输血的风险因素。评估了前24小时内晶体液和成分平衡复苏的效果。
结果
907例患者有足够的记录数据用于分析。224名儿童接受了大量输血，77名接受了超大剂量输血。大量输血和大量输血患者的死亡率显著高于其他患者（分别为25%对10%和19%对9%）。年龄小于4岁、穿透伤和损伤严重程度评分（ISS）大于15与大量输血相关；ISS大于15和穿透伤与超大剂量输血相关。晶体液输注量增加与大量输血和大量输血患者的住院天数和重症监护病房天数显著正相关，与大量输血患者的呼吸机使用天数增加也显著正相关。成分平衡复苏与改善的测量结果无关，在考虑所有输血患者时，独立与较高的死亡率相关。
结论
在该队列中，严重依赖晶体液进行复苏对结果有不利影响。成分平衡复苏并未改善结果，在考虑所有输血患者时与较高的死亡率相关。关于儿童大量输血实施的疗效和临床触发因素，还需要进一步研究。
证据水平
预后研究，IV级。
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