院前血浆复苏与创伤性脑损伤后改善神经学预后相关。
Prehospital plasma resuscitation associated with improved neurologic outcomes after traumatic brain injury.
作者信息
Hernandez Matthew C, Thiels Cornelius A, Aho Johnathon M, Habermann Elizabeth B, Zielinski Martin D, Stubbs James A, Jenkins Donald H, Zietlow Scott P
机构信息
From the Department of Surgery (M.C.H., J.M.A., M.D.Z., D.H.J., S.P.Z.), Division of Trauma Critical Care and General Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (C.A.T., E.B.H.), and Department of Laboratory Medicine and Pathology (J.A.S.), Mayo Clinic, Rochester, Minnesota.
出版信息
J Trauma Acute Care Surg. 2017 Sep;83(3):398-405. doi: 10.1097/TA.0000000000001581.
BACKGROUND
Trauma-related hypotension and coagulopathy worsen secondary brain injury in patients with traumatic brain injuries (TBIs). Early damage control resuscitation with blood products may mitigate hypotension and coagulopathy. Preliminary data suggest resuscitation with plasma in large animals improves neurologic function after TBI; however, data in humans are lacking.
METHODS
We retrospectively identified all patients with multiple injuries age >15 years with head injuries undergoing prehospital resuscitation with blood products at a single Level I trauma center from January 2002 to December 2013. Inclusion criteria were prehospital resuscitation with either packed red blood cells (pRBCs) or thawed plasma as sole colloid resuscitation. Patients who died in hospital and those using anticoagulants were excluded. Primary outcomes were Glasgow Outcomes Score Extended (GOSE) and Disability Rating Score (DRS) at dismissal and during follow-up.
RESULTS
Of 76 patients meeting inclusion criteria, 53% (n = 40) received prehospital pRBCs and 47% (n = 36) received thawed plasma. Age, gender, injury severity or TBI severity, arrival laboratory values, and number of prehospital units were similar (all p > 0.05). Patients who received thawed plasma had an improved neurologic outcome compared to those receiving pRBCs (median GOSE 7 [7-8] vs. 5.5 [3-7], p < 0.001). Additionally, patients who received thawed plasma had improved functionality compared to pRBCs (median DRS 2 [1-3.5] vs. 9 [3-13], p < 0.001). Calculated GOSE and DRS scores during follow-up, median 6 [5-7] months, demonstrated increased function in those resuscitated with thawed plasma compared to pRBCs by both median GOSE (8 [7-8] vs. 6 [6-7], p < 0.001) and DRS (0 [0-1] vs. 4 [2-8], p < 0.001).
CONCLUSION
In critically injured trauma patients with TBI, early resuscitation with thawed plasma is associated with improved neurologic and functional outcomes at discharge and during follow-up compared to pRBCs alone. These preliminary data support the further investigation and use of plasma in the resuscitation of critically injured TBI patients.
LEVEL OF EVIDENCE
Therapeutic, level V.
背景
创伤相关的低血压和凝血功能障碍会加重创伤性脑损伤（TBI）患者的继发性脑损伤。早期使用血液制品进行损伤控制复苏可能会减轻低血压和凝血功能障碍。初步数据表明，在大型动物中使用血浆复苏可改善TBI后的神经功能；然而，缺乏人类相关数据。
方法
我们回顾性确定了2002年1月至2013年12月期间在一家一级创伤中心接受院前血液制品复苏的所有年龄>15岁的多发伤合并头部损伤患者。纳入标准为院前使用浓缩红细胞（pRBCs）或解冻血浆作为唯一胶体复苏。排除在医院死亡的患者和使用抗凝剂的患者。主要结局指标为出院时及随访期间的格拉斯哥扩展预后评分（GOSE）和残疾评定评分（DRS）。
结果
在76例符合纳入标准的患者中，53%（n = 40）接受了院前pRBCs，47%（n = 36）接受了解冻血浆。年龄、性别、损伤严重程度或TBI严重程度、入院实验室检查值以及院前输注单位数量相似（所有p>0.05）。与接受pRBCs的患者相比，接受解冻血浆的患者神经功能结局得到改善（GOSE中位数7 [7 - 8] 对比5.5 [3 - 7]，p<0.001）。此外，与接受pRBCs的患者相比，接受解冻血浆的患者功能改善更明显（DRS中位数2 [1 - 3.5] 对比9 [3 - 13]，p<0.001）。在随访期间（中位数6 [5 - 7] 个月）计算的GOSE和DRS评分显示，与接受pRBCs的患者相比，接受解冻血浆复苏的患者，无论是GOSE中位数（8 [7 - 8] 对比6 [6 - 7]，p<0.001）还是DRS（0 [0 - 1] 对比4 [2 - 8]，p<0.001）均显示功能有所改善。
结论
在重度创伤性TBI患者中，与单独使用pRBCs相比，早期解冻血浆复苏与出院时及随访期间改善的神经和功能结局相关。这些初步数据支持进一步研究并将血浆用于重度创伤性TBI患者的复苏。
证据级别
治疗性，V级。
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