Maher Zoё, Frank Brian, Saillant Noelle, Goldenberg Anna, Dauer Elizabeth, Hazelton Joshua P, Lubitz Andrea, Zhao Huaqing, Cannon Jeremy W, Seamon Mark J
From the Temple University School of Medicine (Z.M., E.D., A.L., H.Z.), Philadelphia; Geisinger Health System (B.F.), Danville, Pennsylvania; Massachusetts General Hospital (N.S.), Boston, Massachusetts; Cooper University (A.G., J.P.H.), Camden, New Jersey; and Perelman School of Medicine, University of Pennsylvania (J.W.C., M.J.S.), Philadelphia, Pennsylvania.
J Trauma Acute Care Surg. 2017 Apr;82(4):680-686. doi: 10.1097/TA.0000000000001384.
The role of systemic intraoperative anticoagulation (SIAC) during surgical repair of major arterial injuries is controversial. Any potential improvement in arterial patency must be weighed against the risk of hemorrhage in these critically injured patients. We hypothesized that SIAC would increase arterial patency without increasing bleeding complications.
We conducted a multi-institution, retrospective cohort study of trauma patients with major vascular injury from 2005 to 2013 in three Level I centers. Arterial injuries of the neck, torso, and proximal extremities requiring operative management were included. Our primary endpoint was maintenance of arterial patency during index hospitalization. Complications related to bleeding were assessed. The association between SIAC and arterial patency was evaluated using chi-square, t test, and multiple logistic regression modeling.
Of 323 study patients, most were male (88%) and injured by gunshot wounds (69%). Patients repaired with SIAC (n = 154) were compared to those repaired without SIAC (n = 169). No difference in age, gender, mechanism, admission heart rate, or concomitant injury was detected between the groups (all p > 0.05). SIAC use was associated with greater arterial patency rates (93% vs. 85%, p = 0.02) without increasing return to OR for bleeding (4% vs. 6%, p = 0.29). After controlling for gender, admission hemodynamics, ISS, injury location, and postoperative anticoagulation, multivariable regression determined that SIAC patients were 2.6 times more likely (OR 2.6, 95% CI 1.1-6.2, p = 0.03) to maintain patency. Patients who maintained arterial patency were then less likely to return to the OR (9% vs. 78%, p < 0.001) with shorter intensive care unit (median 3 vs. 9 days, p < 0.01) and hospital length of stay (median 13 vs. 21 days, p < 0.01).
Patients who underwent operative repair of arterial injuries utilizing SIAC experienced better arterial patency without additional bleeding complications as compared to those repaired without SIAC. Our data suggest that SIAC may improve arterial patency rates after repair and the attributable bleeding risk of SIAC may be overstated.
Therapeutic/care management, level IV.
全身术中抗凝（SIAC）在主要动脉损伤手术修复中的作用存在争议。必须权衡动脉通畅性的任何潜在改善与这些重伤患者出血风险之间的关系。我们假设SIAC会提高动脉通畅性而不增加出血并发症。
我们对2005年至2013年在三个一级中心的患有主要血管损伤的创伤患者进行了一项多机构回顾性队列研究。纳入需要手术治疗的颈部、躯干和近端肢体的动脉损伤。我们的主要终点是在首次住院期间维持动脉通畅。评估与出血相关的并发症。使用卡方检验、t检验和多元逻辑回归模型评估SIAC与动脉通畅性之间的关联。
在323例研究患者中，大多数为男性（88%），受伤原因是枪伤（69%）。将接受SIAC修复的患者（n = 154）与未接受SIAC修复的患者（n = 169）进行比较。两组在年龄、性别、受伤机制、入院心率或合并伤方面均未发现差异（所有p>0.05）。使用SIAC与更高的动脉通畅率相关（93%对85%，p = 0.02），且不会增加因出血返回手术室的比例（4%对6%，p = 0.29）。在控制性别、入院血流动力学、损伤严重度评分（ISS）、损伤部位和术后抗凝后，多变量回归确定接受SIAC治疗的患者维持通畅的可能性高2.6倍（比值比2.6，95%置信区间1.1 - 6.2，p = 0.03）。维持动脉通畅的患者返回手术室的可能性较小（9%对78%，p < 0.001），重症监护病房住院时间较短（中位数3天对9天，p < 0.01），住院总时长较短（中位数13天对21天，p < 0.01）。
与未接受SIAC修复的患者相比，接受SIAC进行动脉损伤手术修复的患者动脉通畅性更好，且无额外出血并发症。我们的数据表明，SIAC可能会提高修复后的动脉通畅率，且SIAC可归因的出血风险可能被高估。
治疗/护理管理，四级。
