高比例血浆复苏不能提高小儿创伤患者的生存率。
High ratio plasma resuscitation does not improve survival in pediatric trauma patients.
作者信息
Cannon Jeremy W, Johnson Michael A, Caskey Robert C, Borgman Matthew A, Neff Lucas P
机构信息
From the Division of Traumatology, Surgical Critical Care & Emergency Surgery (J.W.C.) and the Department of Surgery (R.C.C.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; David Grant Medical Center (J.W.C.), Travis Air Force Base, Fairfield, California; Uniformed Services (J.W.C., M.A.B.), University of the Health Sciences, Bethesda, Maryland; Department of Emergency Medicine (M.A.J.), University of California, Davis, California; Department of Pediatrics (M.A.B.), San Antonio Military Medical Center, Fort Sam Houston, San Antonio, Texas; and Department of Pediatric Surgery (L.P.N.), Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia.
出版信息
J Trauma Acute Care Surg. 2017 Aug;83(2):211-217. doi: 10.1097/TA.0000000000001549.
BACKGROUND
Damage control resuscitation including balanced resuscitation with high ratios of plasma (PLAS) and platelets (PLT) to packed red blood cells (PRBC) improves survival in adult patients. We sought to evaluate the effect of a high ratio PLAS to PRBC resuscitation strategy in massively transfused pediatric patients with combat injuries.
METHODS
The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric trauma patients (<18 years). Burns, drowning, isolated head trauma, and older teens were excluded. Those who received massive transfusion (≥40 mL/kg total blood products in 24 hours) and early deaths who received any blood products were then evaluated. Primary outcomes were mortality at 24 hours and in-hospital. Secondary outcomes included blood product utilization over 24 hours, ventilator-free days, intensive care unit-free days, and hospital length of stay.
RESULTS
The Department of Defense Trauma Registry yielded 4,980 combat-injured pediatric trauma patients, of whom 364 met inclusion criteria. Analysis of PLAS/PRBC ratios across the entire spectrum of possible ratios in these patients demonstrated no clear inflection point for mortality. Using a division between low (LO) and high (HI) ratios of PLAS/PRBC 1:2, there was no difference in all-cause mortality at 24 hours (LO, 9.2% vs. HI, 8.0%; p = 0.75) and hospital discharge (LO, 21.5% vs. HI, 17.1%; p = 0.39). HI ratio patients received less PRBC but more PLAS and PLT and more total blood products. Those in the HI ratio group also had longer hospital length of stay. Regression analysis demonstrated no associated mortality benefit with a HI ratio (hazards ratio, 2.04; 95% confidence interval, 0.48-8.73; p = 0.34).
CONCLUSION
In combat-injured children undergoing a massive transfusion, a high ratio of PLAS/PRBC was not associated with improved survival. Further prospective studies should be performed to determine the optimal resuscitation strategy in critically injured pediatric patients.
LEVEL OF EVIDENCE
Therapeutic study, level III.
背景
损伤控制复苏，包括采用血浆（PLAS）、血小板（PLT）与红细胞悬液（PRBC）高比例的平衡复苏，可提高成年患者的生存率。我们试图评估高比例PLAS与PRBC复苏策略对大量输血的小儿战伤患者的影响。
方法
查询2001年至2013年国防部创伤登记处的小儿创伤患者（<18岁）。排除烧伤、溺水、单纯性头部创伤和年龄较大的青少年。然后评估那些接受大量输血（24小时内总血制品≥40 mL/kg）的患者以及接受任何血制品的早期死亡患者。主要结局为24小时及住院期间的死亡率。次要结局包括24小时内血制品的使用情况、无呼吸机天数、无重症监护病房天数以及住院时间。
结果
国防部创伤登记处有4980名小儿战伤患者，其中364名符合纳入标准。对这些患者所有可能比例范围内的PLAS/PRBC比例进行分析，未发现死亡率有明显的转折点。采用PLAS/PRBC低（LO）高（HI）比例1:2划分，24小时全因死亡率（LO，9.2%对HI，8.0%；p = 0.75）和出院时死亡率（LO，21.5%对HI，17.1%；p = 0.39）均无差异。HI比例组患者接受的PRBC较少，但PLAS、PLT及总血制品较多。HI比例组患者的住院时间也更长。回归分析显示，HI比例与死亡率改善无相关性（风险比，2.04；95%置信区间，0.48 - 8.73；p = 0.34）。
结论
在大量输血的小儿战伤患者中，高比例的PLAS/PRBC与生存率改善无关。应进行进一步的前瞻性研究，以确定重症小儿创伤患者的最佳复苏策略。
证据水平
治疗性研究，III级。
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