严重骨盆骨折时对腹膜外盆腔填塞的需求减少与复苏策略的改善有关。
Reduced need for extraperitoneal pelvic packing for severe pelvic fractures is associated with improved resuscitation strategies.
作者信息
Gaski Iver Anders, Barckman Jeppe, Naess Paal Aksel, Skaga Nils Oddvar, Madsen Jan Erik, Kløw Nils Einar, Flugsrud Gunnar, Gaarder Christine
机构信息
From the Department of Traumatology (I.A.G., P.A.N, C.G), Department of Gastrointestinal Surgery (G.I.A.), Department of Orthopedic Surgery (J.B, J.E.M., G.F.), Department of Anesthesiology (N.O.S), and Department of Radiology (N.E.K), Oslo University Hospital, Ulleval, Oslo, Norway.
出版信息
J Trauma Acute Care Surg. 2016 Oct;81(4):644-51. doi: 10.1097/TA.0000000000001139.
BACKGROUND
Extraperitoneal pelvic packing (EPP) was introduced at Oslo University Hospital Ulleval (OUHU) in 1994. Published studies from other institutions have advocated its application as a first-line therapy in lieu of angiography. Extraperitoneal pelvic packing is invasive with a high risk of complications, and its role remains an issue of discussion. In line with international trends, an updated massive hemorrhage protocol was implemented at OUHU in 2007. We hypothesized a decreased need for EPP owing to the major changes in resuscitation strategies.
METHODS
Retrospective analysis of data from the OUH Trauma Registry and patient charts for the period 2002-2012 was performed. All pelvic fractures with Abbreviated Injury Severity (AIS) score of 3 or higher and/or transfused during the period before intensive care unit admission regardless of the pelvic AIS were included. The population was analyzed for trends and differences between 2002-2006 (P1) and 2007-2012 (P2). Further analysis was performed on the group of patients transfused five or more units of red blood cells (RBCs).
RESULTS
We included 648 patients (P1, 297; P2, 351). There was no difference in median injury severity score, pelvic AIS, or age between the two periods. Median base deficit on admission was higher in P2 (4.2 vs 3.3 mmol/L; p < 0.01). The EPP rate decreased from P1 to P2 (17-10%; p < 0.01). A similar reduction in the angiography rate (15% vs 9%; p < 0.01) was observed, with a concomitant decrease in hemorrhage-related deaths (10% vs 5%; p = 0.01). The subgroup analysis of patients transfused five or more units of RBCs revealed significant increase in the use of plasma and platelets in P2. Multiple logistic regression models for the subgroup transfused five or more units of RBCs confirm the change in resuscitation strategy to be significantly associated with reduced EPP, and identifying admission in P2 to be associated with a 63% decreased odds ratio for EPP.
CONCLUSIONS
The EPP and angiography rates for exsanguinating pelvic injuries have decreased with improved resuscitation strategies, reducing RBC requirements and hemorrhage-related deaths.
LEVEL OF EVIDENCE
Therapeutic study, level IV.
背景
1994年，奥斯陆大学医院于勒瓦尔分院（OUHU）引入了腹膜外盆腔填塞术（EPP）。其他机构发表的研究主张将其作为替代血管造影的一线治疗方法。腹膜外盆腔填塞术具有侵入性，并发症风险高，其作用仍存在争议。顺应国际趋势，OUHU于2007年实施了更新后的大出血治疗方案。我们推测由于复苏策略的重大改变，对EPP的需求会减少。
方法
对OUH创伤登记处2002年至2012年期间的数据以及患者病历进行回顾性分析。纳入所有在重症监护病房入院前期间骨盆损伤简略损伤严重程度（AIS）评分为3或更高和/或接受输血的患者，无论骨盆AIS如何。分析了2002 - 2006年（P1）和2007 - 2012年（P2）期间的总体趋势和差异。对输注五个或更多单位红细胞（RBC）的患者组进行了进一步分析。
结果
我们纳入了648例患者（P1组297例；P2组351例）。两个时期之间的损伤严重程度评分中位数、骨盆AIS或年龄没有差异。P2组入院时的碱缺失中位数更高（4.2 vs 3.3 mmol/L；p < 0.01）。EPP率从P1组到P2组下降（17% - 10%；p < 0.01）。血管造影率也有类似下降（15% vs 9%；p < 0.01），同时出血相关死亡率下降（10% vs 5%；p = 0.01）。对输注五个或更多单位RBC的患者进行亚组分析显示，P2组血浆和血小板的使用显著增加。对输注五个或更多单位RBC的亚组进行的多因素逻辑回归模型证实，复苏策略的改变与EPP减少显著相关，并确定在P2组入院与EPP的比值比降低63%相关。
结论
随着复苏策略的改进，出血性骨盆损伤的EPP和血管造影率降低，并减少了RBC需求和出血相关死亡。
证据水平
治疗性研究，IV级。
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