Trauma Unit, Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.
Department of Intensive Care Medicine, Academic Medical Centre, Amsterdam, The Netherlands.
Br J Surg. 2017 Feb;104(3):222-229. doi: 10.1002/bjs.10330. Epub 2017 Jan 12.
The combined effects of balanced transfusion ratios and use of procoagulant and antifibrinolytic therapies on trauma-induced exsanguination are not known. The aim of this study was to investigate the combined effect of transfusion ratios, tranexamic acid and products containing fibrinogen on the outcome of injured patients with bleeding.
A prospective multicentre observational study was performed in six level 1 trauma centres. Injured patients who received at least 4 units of red blood cells (RBCs) were analysed and divided into groups receiving a low (less than 1 : 1) or high (1 or more : 1) ratio of plasma or platelets to RBCs, and in receipt or not of tranexamic acid or fibrinogen products (fibrinogen concentrates or cryoprecipitate). Logistic regression models were used to assess the effect of transfusion strategies on the outcomes 'alive and free from massive transfusion' (at least 10 units of RBCs in 24 h) and early 'normalization of coagulopathy' (defined as an international normalized ratio of 1·2 or less).
A total of 385 injured patients with ongoing bleeding were included in the study. Strategies that were independently associated with an increased number of patients alive and without massive transfusion were a high platelet to RBC ratio (odds ratio (OR) 2·67, 95 per cent c.i. 1·24 to 5·77; P = 0·012), a high plasma to RBC ratio (OR 2·07, 1·03 to 4·13; P = 0·040) and treatment with tranexamic acid (OR 2·71, 1·29 to 5·71; P = 0·009). No strategies were associated with correction of coagulopathy.
A high platelet or plasma to RBC ratio, and use of tranexamic acid were associated with a decreased need for massive transfusion and increased survival in injured patients with bleeding. Early normalization of coagulopathy was not seen for any transfusion ratio, or for use of tranexamic acid or fibrinogen products.
平衡输血比例以及使用促凝和抗纤溶治疗对创伤性失血的综合影响尚不清楚。本研究旨在探讨输血比例、氨甲环酸和纤维蛋白原制品联合应用对出血创伤患者结局的影响。
在 6 家 1 级创伤中心进行了一项前瞻性多中心观察性研究。对至少输注 4 单位红细胞（RBC）的创伤患者进行分析，并分为接受低（<1：1）或高（1 或更多：1）比例的血浆或血小板与 RBC 输注的患者，以及接受或不接受氨甲环酸或纤维蛋白原制品（纤维蛋白原浓缩物或冷沉淀）的患者。使用逻辑回归模型评估输血策略对“存活且无需大量输血”（24 小时内输注至少 10 单位 RBC）和早期“凝血功能正常化”（定义为国际标准化比值为 1.2 或以下）结局的影响。
共纳入 385 例正在出血的创伤患者。与存活且无需大量输血的患者数量增加独立相关的策略包括高血小板与 RBC 比值（比值比（OR）2.67，95%置信区间（CI）1.24 至 5.77；P=0.012）、高血浆与 RBC 比值（OR 2.07，1.03 至 4.13；P=0.040）和氨甲环酸治疗（OR 2.71，1.29 至 5.71；P=0.009）。没有任何策略与凝血功能的纠正相关。
高血小板或高血浆与 RBC 比值以及使用氨甲环酸与出血创伤患者对大量输血的需求减少和生存率提高相关。任何输血比例或使用氨甲环酸或纤维蛋白原制品均未出现凝血功能的早期正常化。
