比率驱动复苏可预测战伤患者的早期筋膜闭合。
Ratio-driven resuscitation predicts early fascial closure in the combat wounded.
作者信息
Glaser Jacob, Vasquez Matthew, Cardarelli Cassandra, Dunne James, Elster Eric, Hathaway Emily, Bograd Benjamin, Safford Shawn, Rodriguez Carlos
机构信息
From the Walter Reed National Military Medical Center (J.G., M.V., C.C., E.E., E.H., B.B., S.S., C.R.); and Uniformed Services University of Health Sciences (E.E., S.S.), Bethesda; and Division of Trauma and Surgical Critical Care (J.G.), Department of Surgery, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland; and Memorial University Medical Center (J.D.), Savannah, Georgia.
出版信息
J Trauma Acute Care Surg. 2015 Oct;79(4 Suppl 2):S188-92. doi: 10.1097/TA.0000000000000741.
BACKGROUND
Operation Iraqi Freedom and Operation Enduring Freedom have seen the highest rates of combat casualties since Vietnam. These casualties often require massive transfusion (MT) and immediate surgical attention to control hemorrhage. Clinical practice guidelines dictate ratio-driven resuscitation (RDR) for patients requiring MT. With the transition from crystalloid to blood product resuscitation, we have seen fewer open abdomens in combat casualties. We sought to determine the effect RDR has on achieving early definitive abdominal fascial closure in combat casualties undergoing exploratory laparotomy.
METHODS
Records of 1,977 combat casualties admitted to a single US military hospital from April 2003 to December 2011 were reviewed. Patients receiving an MT and laparotomy in theater constituted the study cohort. The cohort was divided into RDR, defined as a ratio of 0.8-U to 1.2-U packed red blood cells to 1-U fresh frozen plasma, and No-RDR groups. Age, injury patterns, mechanism of injury, injury severity, blood products, number of laparotomies, and days to fascial closure were collected. Assessed outcomes were number of days (early ≤ 2 days) and number of laparotomies to achieve fascial closure.
RESULTS
The mean age of the study cohort (n = 172) was 24.0 years, and mean Injury Severity Score (ISS) was 24.8. Improvised explosive device blast was the most common mechanism of injury (74.4%). The cohort was divided into RDR patients (n = 73) and no RDR (n = 99). There was no difference in mean age, mean ISS, or rate of nontherapeutic exploratory laparotomies between the groups. RDR patients had a significantly lower abdominal injury rate (34.2% vs. 72.7%, p < 0.01), had fewer laparotomies (2.7 vs. 4.3, p = 0.003), and achieved primary fascial closure faster (2.4 days vs. 7.2 days, p = 0.004). On multivariate analysis, RDR (2.74; 95% confidence interval, 1.44-5.2) was an independent predictor for early fascial closure.
CONCLUSION
Adherence to RDR guidelines resulted in significantly decreased number of abdominal operations and was identified as an independent predictor for early fascial closure. Further investigation is warranted to validate these findings.
LEVEL OF EVIDENCE
Therapeutic study, level III.
背景
自越南战争以来，“伊拉克自由行动”和“持久自由行动”的战斗伤亡率最高。这些伤亡人员常常需要大量输血（MT）并立即进行外科手术以控制出血。临床实践指南规定了对需要大量输血的患者采用比例驱动复苏（RDR）。随着从晶体液复苏向血液制品复苏的转变，我们发现战斗伤亡人员中开放性腹部的情况减少了。我们试图确定比例驱动复苏对接受剖腹探查术的战斗伤亡人员实现早期确定性腹部筋膜闭合的影响。
方法
回顾了2003年4月至2011年12月间收治于一家美国军事医院的1977名战斗伤亡人员的记录。在战区接受大量输血和剖腹手术的患者构成研究队列。该队列分为比例驱动复苏组（定义为浓缩红细胞与新鲜冰冻血浆的比例为0.8 - 1.2单位比1单位）和非比例驱动复苏组。收集了年龄、损伤类型、损伤机制、损伤严重程度、血液制品、剖腹手术次数以及筋膜闭合天数。评估的结果是实现筋膜闭合的天数（早期≤2天）和剖腹手术次数。
结果
研究队列（n = 172）的平均年龄为24.0岁，平均损伤严重程度评分（ISS）为24.8。简易爆炸装置爆炸是最常见的损伤机制（74.4%）。该队列分为比例驱动复苏患者（n = 73）和非比例驱动复苏患者（n = 99）。两组之间的平均年龄、平均ISS或非治疗性剖腹探查术的发生率没有差异。比例驱动复苏患者的腹部损伤率显著更低（34.2%对72.7%，p < 0.01），剖腹手术次数更少（2.7次对4.3次，p = 0.003），并且更快实现了一期筋膜闭合（2.4天对7.2天，p = 0.004）。在多变量分析中，比例驱动复苏（2.74；95%置信区间，1.44 - 5.2）是早期筋膜闭合的独立预测因素。
结论
遵循比例驱动复苏指南导致腹部手术数量显著减少，并被确定为早期筋膜闭合的独立预测因素。有必要进行进一步研究以验证这些发现。
证据水平
治疗性研究，III级。
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