Mclennan Jacqueline V, Mackway-Jones K C, Horne S T, Body R
Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Academia & Research), Medical Directorate, ICT Centre, Birmingham, UK.
Royal Stoke Hospital, University Hospital North Midlands NHS Trust, Staffordshire, UK.
J R Army Med Corps. 2017 Aug;163(4):259-265. doi: 10.1136/jramc-2016-000702. Epub 2017 Mar 20.
Trauma patients requiring massive blood transfusion (MBT) have high morbidity and mortality: early and aggressive use of blood products during immediate resuscitation may improve survival. There is currently a lack of evidence to guide initial identification of these patients which is especially important in areas where plasma may need to be thawed. In the absence of this evidence, this study aimed to robustly evaluate expert opinion by using a Delphi process to identify predictors of massive transfusion. This process can be used to ensure that decision rules include variables that have clinical validity, which may improve translation of rules into clinical practice.
An international panel of 35 experts was identified through expert advice against specific criteria. Military and civilian experts from the fields of emergency medicine, critical care, anaesthesia, prehospital care, haematology and general/trauma surgery were included. The Delphi Study was carried out over three rounds. Consensus level was predefined at 80%.
195 statements were generated by the panel of which 97 (49.7%) achieved consensus at the 80% level by the end of round 3. Strikingly no clinical observations reached consensus individually. Metabolic acidosis of a base excess of -5.0 or worse, lactate >5 mmol/L and a low haematocrit on arrival were all considered predictive. Some patterns of injury, but few mechanisms of injury, were considered highly predictive of the need of MBT.
This Delphi process has produced a list of parameters that expert clinicians felt were predictive for MBT. This list can be used to inform the generation of decision rules. It is of note that many factors used in current decision rules were not valued by clinical experts-this may be a cause for poor uptake of those rules.
需要大量输血（MBT）的创伤患者具有较高的发病率和死亡率：在即刻复苏期间早期积极使用血液制品可能会提高生存率。目前缺乏指导这些患者初始识别的证据，这在可能需要解冻血浆的地区尤为重要。在缺乏此类证据的情况下，本研究旨在通过德尔菲法对专家意见进行严格评估，以确定大量输血的预测因素。该方法可用于确保决策规则纳入具有临床有效性的变量，这可能会改善规则在临床实践中的应用。
通过针对特定标准的专家建议确定了一个由35名专家组成的国际小组。成员包括来自急诊医学、重症监护、麻醉、院前急救、血液学以及普通/创伤外科领域的军事和 civilian 专家。德尔菲研究分三轮进行。共识水平预先设定为80%。
专家小组共提出195条陈述，其中97条（49.7%）在第3轮结束时达到了80%的共识水平。引人注目的是，没有任何一项临床观察单独达成共识。碱剩余≤ -5.0的代谢性酸中毒、乳酸>5 mmol/L以及入院时血细胞比容低均被视为具有预测性。一些损伤模式，但很少有损伤机制，被认为对大量输血的需求具有高度预测性。
这一德尔菲法得出了一份专家临床医生认为可预测大量输血的参数清单。该清单可用于指导决策规则的制定。值得注意的是，当前决策规则中使用的许多因素未得到临床专家的重视，这可能是这些规则应用不佳的一个原因。
