分秒必争：首次大量输血冷却器的交付时间及其对死亡率的影响。
Every minute counts: Time to delivery of initial massive transfusion cooler and its impact on mortality.
作者信息
Meyer David E, Vincent Laura E, Fox Erin E, OʼKeeffe Terence, Inaba Kenji, Bulger Eileen, Holcomb John B, Cotton Bryan A
机构信息
From the Department of Surgery, Division of Acute Care Surgery, McGovern School of Medicine (D.E.M.), University of Texas Health Sciences Center; The Center for Translational Injury Research (L.E.V., E.E.F.), Houston, Texas; Department of Surgery, Division of Trauma, Critical Care, Burn, and Emergency Surgery, College of Medicine (T.O.K.), University of Arizona, Tucson, Arizona; Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, The Keck School of Medicine (K.I.) Los Angeles County Hospital, Los Angeles, California; Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, Harborview Medical Center (E.B.), The University of Washington Medical School, Seattle, Washington; and Department of Surgery, Division of Acute Care Surgery McGovern School of Medicine, The Center for Translational Injury Research (J.B.H., B.A.C.), University of Texas Health Sciences Center, Houston, Texas.
出版信息
J Trauma Acute Care Surg. 2017 Jul;83(1):19-24. doi: 10.1097/TA.0000000000001531.
BACKGROUND
American College of Surgeons Trauma Quality Improvement Best Practices recommends initial massive transfusion (MT) cooler delivery within 15 minutes of protocol activation, with a goal of 10 minutes. The current study sought to examine the impact of timing of first cooler delivery on patient outcomes.
METHODS
Patients predicted to receive MT at 12 Level I trauma centers were randomized to two separate transfusion ratios as described in the PROPPR trial. Assessment of Blood Consumption score or clinician gestalt prediction of MT was used to randomize patients and call for initial study cooler. In this planned subanalysis, the time to MT protocol activation and time to delivery of the initial cooler were evaluated. The impact of these times on mortality and time to hemostasis were examined using both Wilcoxon rank sum and linear and logistic regression.
RESULTS
Among 680 patients, the median time from patient arrival to MT protocol activation was 9 minutes with a median time from MT activation call to delivery of first cooler of 8 minutes. An increase in both time to MT activation and time to arrival of first cooler were associated with prolonged time to achieving hemostasis (coefficient, 1.09; p = 0.001 and coefficient, 1.16; p < 0.001, respectively). Increased time to MT activation and time to arrival of first cooler were associated with increased mortality (odds ratio [OR], 1.02; p = 0.009 and OR, 1.02; p = 0.012, respectively). Controlling for injury severity, physiology, resuscitation intensity, and treatment arm (1:1:1 vs. 1:1:2), increased time to arrival of first cooler was associated with an increased mortality at 24 hours (OR, 1.05; p = 0.035) and 30 days (OR, 1.05, p = 0.016).
CONCLUSION
Delays in MT protocol activation and delays in initial cooler arrival were associated with prolonged time to achieve hemostasis and an increase in mortality. Independent of products ratios, every minute from time of MT protocol activation to time of initial cooler arrival increases odds of mortality by 5%.
LEVEL OF EVIDENCE
Prognostic, level II; Therapeutic, level III.
背景
美国外科医师学会创伤质量改进最佳实践建议在方案启动后15分钟内送达首批大量输血（MT）冷却器，目标是10分钟。本研究旨在探讨首次冷却器送达时间对患者预后的影响。
方法
在12个一级创伤中心预计接受MT的患者按照PROPPR试验中描述的方法随机分为两种不同的输血比例。使用血液消耗评分评估或临床医生对MT的整体预测来随机分组并要求送达首批研究用冷却器。在这项计划中的亚分析中，评估了MT方案启动时间和首批冷却器送达时间。使用Wilcoxon秩和检验以及线性和逻辑回归分析了这些时间对死亡率和止血时间的影响。
结果
在680例患者中，从患者到达至MT方案启动的中位时间为9分钟，从MT启动呼叫至首批冷却器送达的中位时间为8分钟。MT启动时间和首批冷却器到达时间的增加均与止血时间延长相关（系数分别为1.09；p = 0.001和系数1.16；p < 0.001）。MT启动时间和首批冷却器到达时间的增加与死亡率增加相关（比值比[OR]分别为1.02；p = 0.009和OR，1.02；p = 0.012）。在控制损伤严重程度、生理状态、复苏强度和治疗组（1:1:1 vs. 1:1:2）后，首批冷却器到达时间的增加与24小时（OR，1.05；p = 0.035）和30天（OR，1.05，p = 0.016）的死亡率增加相关。
结论
MT方案启动延迟和首批冷却器到达延迟与止血时间延长和死亡率增加相关。与产品比例无关，从MT方案启动到首批冷却器到达的每一分钟都会使死亡率增加5%。
证据级别
预后，二级；治疗，三级。
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