Stone Melvin E, Kalata Stanley, Liveris Anna, Adorno Zachary, Yellin Shira, Chao Edward, Reddy Srinivas H, Jones Michael, Vargas Carlos, Teperman Sheldon
Department of Surgery, Jacobi Medical Center Bronx, NY, United States; Albert Einstein College of Medicine, Bronx, NY, United States.
Albert Einstein College of Medicine, Bronx, NY, United States.
Injury. 2017 Jan;48(1):51-57. doi: 10.1016/j.injury.2016.07.007. Epub 2016 Jul 5.
Critical administration threshold (≥3 units of packed red blood cells/h or CAT+) has been proposed as a new definition for massive transfusion (MT) that includes volume and rate of blood transfusion. CAT+ has been shown to eliminate survivor bias and be a better predictor of mortality than the traditional MT (>10 units/24h). End-tidal CO (ET CO) negatively correlates with lactate and is an early predictor of shock in trauma patients. We conducted a pilot study to test the hypothesis that low ET CO on admission predicts CAT+.
ET CO via capnography and serum lactate were prospectively collected on admission for 131 patients requiring trauma team activation. Demographic data were obtained from patient charts. Excluded were patients with isolated head injuries, traumatic arrests, or pre-hospital intubations. CAT± status was determined for each hour up to 6h from admission as described; likewise, MT± status was determined up to 24h from admission.
After exclusion criteria, 67 patients were analyzed. Mean age was 41.2 (SD 18.5). Thirty-three patients had a blunt mechanism of injury (49%), median ISS was 9 (interquartile range 4-19), and there were 6 deaths (9%). ET CO and lactate were negatively correlated by Spearman rank-based correlation (rho=-0.41, p=0.0006). Twenty-one (31%) and 8 (12%) patients were CAT+ and traditional MT+, respectively. There were a significantly greater proportion of patients with ISS>15, ET CO <35, or who died found to be CAT+. A binomial logistic regression model adjusting for age, SBP <90, HR, and ISS >15 revealed ET CO < 35 to be independently predictive of CAT+ (OR 9.24, 95% CI 1.51-56.57, p=0.016).
This pilot study demonstrated that low ET CO had strong association with standard indicators for shock and was predictive of patients meeting CAT+ criteria in the first 6h after admission. Further study to verify these results and to elucidate CAT criteria's association with mortality will require a larger sample size.
危急输血阈值（≥3单位浓缩红细胞/小时或CAT+）已被提议作为大量输血（MT）的新定义，其中包括输血的量和速度。研究表明，CAT+可消除幸存者偏差，并且比传统的大量输血定义（>10单位/24小时）能更好地预测死亡率。呼气末二氧化碳分压（ET CO）与乳酸呈负相关，是创伤患者休克的早期预测指标。我们进行了一项初步研究，以检验入院时低ET CO可预测CAT+这一假设。
前瞻性收集了131例需要创伤团队救治的患者入院时通过二氧化碳描记法测得的ET CO和血清乳酸水平。人口统计学数据从患者病历中获取。排除单纯头部受伤、创伤性心跳骤停或院前插管的患者。按照上述方法确定入院后6小时内每小时的CAT±状态；同样，确定入院后24小时内的MT±状态。
根据排除标准，对67例患者进行了分析。平均年龄为41.2岁（标准差18.5）。33例患者为钝性损伤机制（49%），损伤严重度评分（ISS）中位数为9（四分位间距4-19），6例死亡（9%）。ET CO与乳酸通过基于Spearman秩次的相关性分析呈负相关（rho=-0.41，p=0.0006）。分别有21例（31%）和8例（12%）患者为CAT+和传统大量输血阳性。ISS>15、ET CO<35或死亡的患者中，CAT+患者的比例显著更高。校正年龄、收缩压<90、心率和ISS>15的二项逻辑回归模型显示，ET CO<35可独立预测CAT+（比值比9.24，95%置信区间1.51-56.57，p=0.016）。
这项初步研究表明，低ET CO与休克的标准指标密切相关，并且可预测入院后6小时内符合CAT+标准的患者。进一步研究以验证这些结果并阐明CAT标准与死亡率的关联将需要更大的样本量。
