骨盆骨折后出血的血管造影栓塞术：是否到了范式转变的时候？
Angiographic embolization for hemorrhage following pelvic fracture: Is it "time" for a paradigm shift?
作者信息
Tesoriero Ronald Brian, Bruns Brandon R, Narayan Mayur, Dubose Joseph, Guliani Sundeep S, Brenner Megan L, Boswell Sharon, Stein Deborah M, Scalea Thomas M
机构信息
From the Division of Critical Care (R.B.T., B.R.B., M.N., M.L.B., S.B., D.M.S., T.M.S.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (J.D.), David Grant Medical Center, Travis AFB, California, and Voluntary Faculty, University of California-Davis, Sacramento, California; and Department of Surgery (S.S.G.), University of New Mexico School of Medicine, Albuquerque, New Mexico.
出版信息
J Trauma Acute Care Surg. 2017 Jan;82(1):18-26. doi: 10.1097/TA.0000000000001259.
INTRODUCTION
Major pelvic disruption with hemorrhage has a high rate of lethality. Angiographic embolization remains the mainstay of treatment. Delays to angiography have been shown to worsen outcomes in part because time spent awaiting mobilization of resources needed to perform angiography allows ongoing hemorrhage. Alternative techniques like pelvic preperitoneal packing and aortic balloon occlusion now exist. We hypothesized that time to angiographic embolization at our Level 1 trauma center would be longer than 90 minutes.
METHODS
A retrospective review was performed of patients with pelvic fracture who underwent pelvic angiography at our trauma center over a 10-year period. The trauma registry was queried for age, sex, injury severity score, hemodynamic instability (HI) on presentation, and transfusion requirements within 24 hours. Charts were reviewed for time to angiography, embolization, and mortality.
RESULTS
A total of 4712 patients were admitted with pelvic fractures during the study period, 344 (7.3%) underwent pelvic angiography. Median injury severity score was 29. Median 24-hour transfusion requirements were five units of red blood cells and six units of fresh frozen plasma. One hundred fifty-one patients (43.9%) presented with HI and 104 (30%) received massive transfusion (MT). Median time to angiography was 286 minutes (interquartile range, 210-378). Times were significantly shorter when stratified for HI (HI, 264 vs stable 309 minutes; p = 0.003), and MT (MT, 230 vs non-MT, 317 minutes; p < 0.001), but still took nearly 4 hours. Overall mortality was 18%. Hemorrhage (35.5%) and sepsis/multiple-organ failure (43.5%) accounted for most deaths.
CONCLUSION
Pelvic fracture hemorrhage remains a management challenge. In this series, the median time to embolization was more than 5 hours. Nearly 80% of deaths could be attributed to early uncontrolled hemorrhage and linked to delays in hemostasis. Earlier intervention by Acute Care Surgeons with techniques like preperitoneal packing, aortic balloon occlusion, and use of hybrid operative suites may improve outcomes.
LEVEL OF EVIDENCE
Therapeutic study, level V.
引言
伴有出血的严重骨盆骨折致死率很高。血管造影栓塞术仍是主要的治疗方法。已证实血管造影延迟会使预后恶化，部分原因是等待进行血管造影所需资源调配的时间里出血仍在持续。现在有了诸如骨盆腹膜前填塞和主动脉球囊阻断等替代技术。我们推测在我们的一级创伤中心进行血管造影栓塞术的时间会超过90分钟。
方法
对在10年期间于我们创伤中心接受骨盆血管造影的骨盆骨折患者进行回顾性研究。查询创伤登记系统以获取年龄、性别、损伤严重程度评分、入院时的血流动力学不稳定情况（HI）以及24小时内的输血需求。查阅病历以获取血管造影、栓塞及死亡率的时间。
结果
在研究期间共有4712例骨盆骨折患者入院，其中344例（7.3%）接受了骨盆血管造影。损伤严重程度评分中位数为29分。24小时输血需求中位数为5单位红细胞和6单位新鲜冰冻血浆。151例患者（43.9%）存在血流动力学不稳定情况，104例（30%）接受了大量输血（MT）。血管造影的中位时间为286分钟（四分位间距，210 - 378分钟）。按血流动力学不稳定情况分层时时间明显更短（血流动力学不稳定情况，264分钟对稳定情况309分钟；p = 0.003），以及按大量输血情况分层时（大量输血，230分钟对非大量输血，317分钟；p < 0.001），但仍将近4小时。总体死亡率为18%。出血（35.5%）和脓毒症/多器官功能衰竭（43.5%）是主要死因。
结论
骨盆骨折出血仍是一个治疗难题。在本系列研究中，栓塞的中位时间超过5小时。近80%的死亡可归因于早期出血未得到控制，并与止血延迟有关。急性外科医生采用腹膜前填塞、主动脉球囊阻断等技术以及使用混合手术室进行早期干预可能会改善预后。
证据水平
治疗性研究，V级。
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