烧伤及软组织切除术中的急性失血：血液制品复苏实践的观察性研究及重点综述
Acute blood loss during burn and soft tissue excisions: An observational study of blood product resuscitation practices and focused review.
作者信息
Pidcoke Heather F, Isbell Claire L, Herzig Maryanne C, Fedyk Chriselda G, Schaffer Beverly S, Chung Kevin K, White Christopher E, Wolf Steven E, Wade Charles E, Cap Andrew P
机构信息
From the US Army Institute of Surgical Research (H.F.P., M.C.H., C.G.F., B.S.S., K.K.C., C.E.Wh., A.P.C.), San Antonio; Department of Surgery (C.L.I, S.E.W.), University of Texas Southwestern Medical Center, Dallas; and Department of Surgery and the Center for Translational Injury Research (C.E.Wa.), University of Texas Health Sciences Center, Houston, Texas; and Uniformed Services University of the Health Sciences (K.K.C., A.P.C.), Bethesda, Maryland.
出版信息
J Trauma Acute Care Surg. 2015 Jun;78(6 Suppl 1):S39-47. doi: 10.1097/TA.0000000000000627.
BACKGROUND
Many military and civilian centers have shifted to a damage-control resuscitation approach, focused on providing oxygen-carrying capacity while simultaneously mitigating coagulopathy with a balanced ratio of platelets and plasma to red blood cells. It is unclear to what degree this strategy is used during burn or soft tissue excision. Here, we characterized blood product transfusion during burn and soft tissue surgery and reviewed the published literature regarding intraoperative coagulation changes. We hypothesized that blood product resuscitation during burn and soft tissue excision is not hemostatic and would be insufficient to address hemorrhage-induced coagulopathy.
METHODS
Consented adult patients were enrolled into an institutional review board-approved prospective observational study. Number, component type, volume, and age of the blood products transfused were recorded during burn excision/grafting or soft tissue debridement. Component bags (packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate) were collected, and the remaining sample was harvested from the bag and tubing. Aliquots of 1/1,000th the original volume of each blood product were obtained and combined, producing an amalgam sample containing the same ratio of product transfused. Platelet count, rotational thromboelastometry, and impedance aggregometry were measured. Significance was set at p < 0.05.
RESULTS
Amalgamated transfusate samples produced abnormally weak clots (p ≤ 0.001) particularly if they did not contain platelets. Clot strength (48.8 [2.6] mm; reference range, 49-71 mm) for platelet-containing amalgams was below the lower limit of the reference range despite platelet-red blood cell ratios greater than 1:1. Platelet aggregation was abnormally low; transfused platelets were functionally inferior to native platelets.
CONCLUSION
Our study and focused review demonstrate that further work is needed to fully understand the needs of patients undergoing tissue excision. The three studies reviewed and the results of our observational work suggest that coagulopathy and thrombocytopenia may contribute to intraoperative hemorrhage. Blood product resuscitation during burn and soft tissue excision is not hemostatic.
LEVEL OF EVIDENCE
Epidemiologic study, level V.
背景
许多军事和民用中心已转向损伤控制复苏方法，重点是提供携氧能力，同时通过使血小板、血浆与红细胞保持平衡比例来减轻凝血病。目前尚不清楚这种策略在烧伤或软组织切除过程中使用的程度。在此，我们对烧伤和软组织手术期间的血液制品输注情况进行了描述，并回顾了已发表的关于术中凝血变化的文献。我们假设烧伤和软组织切除期间的血液制品复苏不能止血，且不足以解决出血引起的凝血病。
方法
同意参与的成年患者被纳入一项经机构审查委员会批准的前瞻性观察性研究。在烧伤切除/植皮或软组织清创过程中记录输注的血液制品的数量、成分类型、体积和患者年龄。收集成分袋（浓缩红细胞、新鲜冰冻血浆、血小板和冷沉淀），并从袋子和管道中采集剩余样本。获取每种血液制品原始体积千分之一的等分试样并合并，制成包含相同输注制品比例的混合样本。测量血小板计数、旋转血栓弹力图和阻抗聚集法。显著性设定为p < 0.05。
结果
混合输注液样本形成的凝块异常脆弱（p≤0.001），特别是如果它们不含血小板。尽管血小板与红细胞的比例大于1:1，但含血小板混合样本的凝块强度（48.8 [2.6] 毫米；参考范围为49 - 71毫米）低于参考范围的下限。血小板聚集异常低；输注的血小板在功能上不如天然血小板。
结论
我们的研究和重点综述表明，需要进一步开展工作以充分了解接受组织切除患者的需求。所综述的三项研究以及我们观察性工作的结果表明，凝血病和血小板减少症可能导致术中出血。烧伤和软组织切除期间的血液制品复苏不能止血。
证据级别
流行病学研究，V级。
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