急诊创伤剖腹术后的死亡率：一项多中心回顾性研究。
Mortality after emergent trauma laparotomy: A multicenter, retrospective study.
作者信息
Harvin John A, Maxim Tom, Inaba Kenji, Martinez-Aguilar Myriam A, King David R, Choudhry Asad J, Zielinski Martin D, Akinyeye Sam, Todd S Rob, Griffin Russell L, Kerby Jeffrey D, Bailey Joanelle A, Livingston David H, Cunningham Kyle, Stein Deborah M, Cattin Lindsay, Bulger Eileen M, Wilson Alison, Undurraga Perl Vicente J, Schreiber Martin A, Cherry-Bukowiec Jill R, Alam Hasan B, Holcomb John B
机构信息
From the The University of Texas McGovern Medical School at Houston (J.A.H., J.B.H.), Houston, Texas; The University of Southern California Keck School of Medicine (T.M., K.I.), Los Angeles, California; Harvard Medical School (M.A.M.-A., D.R.K.), Boston, Massachusetts; Mayo Clinic (A.J.C., M.D.Z.), Rochester, Minnesota; Baylor College of Medicine (S.A., S.R.T.), Houston, Texas; The University of Alabama School of Medicine (R.L.G., J.D.K.), Birmingham, Alabama; The Rutgers New Jersey Medical School (J.A.B., D.H.L.), Newark, New Jersey; The University of Maryland School of Medicine (K.C., D.M.S.), Baltimore, Maryland; The University of Washington Harborview Medical Center (L.C., E.M.B.), Seattle, Washington; The West Virginia University School of Medicine (A.W.), Morgantown, West Virginia; Oregon Health & Science University (V.J.U.P., M.A.S.), Portland, Oregon; and The University of Michigan Medical School (J.R.C.-B., H.B.A.), Ann Arbor, Michigan.
出版信息
J Trauma Acute Care Surg. 2017 Sep;83(3):464-468. doi: 10.1097/TA.0000000000001619.
BACKGROUND
Two decades ago, hypotensive trauma patients requiring emergent laparotomy had a 40% mortality. In the interim, multiple interventions to decrease hemorrhage-related mortality have been implemented but few have any documented evidence of change in outcomes for patients requiring emergent laparotomy. The purpose of this study was to determine current mortality rates for patients undergoing emergent trauma laparotomy.
METHODS
A retrospective cohort of all adult, emergent trauma laparotomies performed in 2012 to 2013 at 12 Level I trauma centers was reviewed. Emergent trauma laparotomy was defined as emergency department (ED) admission to surgical start time in 90 minutes or less. Hypotension was defined as arrival ED systolic blood pressure (SBP) ≤90 mm Hg. Cause and time to death was also determined. Continuous data are presented as median (interquartile range [IQR]).
RESULTS
One thousand seven hundred six patients underwent emergent trauma laparotomy. The cohort was predominately young (31 years; IQR, 24-45), male (84%), sustained blunt trauma (67%), and with moderate injuries (Injury Severity Score, 19; IQR, 10-33). The time in ED was 24 minutes (IQR, 14-39) and time from ED admission to surgical start was 42 minutes (IQR, 30-61). The most common procedures were enterectomy (23%), hepatorrhaphy (20%), enterorrhaphy (16%), and splenectomy (16%). Damage control laparotomy was used in 38% of all patients and 62% of hypotensive patients. The Injury Severity Score for the entire cohort was 19 (IQR, 10-33) and 29 (IQR, 18-41) for the hypotensive group. Mortality for the entire cohort was 21% with 60% of deaths due to hemorrhage. Mortality in the hypotensive group was 46%, with 65% of deaths due to hemorrhage.
CONCLUSION
Overall mortality rate of a trauma laparotomy is substantial (21%) with hemorrhage accounting for 60% of the deaths. The mortality rate for hypotensive patients (46%) appears unchanged over the last two decades and is even more concerning, with almost half of patients presenting with an SBP of 90 mm Hg or less dying.
背景
二十年前，需要紧急剖腹手术的创伤性低血压患者死亡率为40%。在此期间，已实施了多种降低出血相关死亡率的干预措施，但很少有文献证明对需要紧急剖腹手术的患者的治疗结果有改变。本研究的目的是确定接受紧急创伤剖腹手术患者的当前死亡率。
方法
回顾性分析了2012年至2013年在12个一级创伤中心进行的所有成年紧急创伤剖腹手术病例。紧急创伤剖腹手术定义为从急诊科入院到手术开始时间在90分钟或更短。低血压定义为到达急诊科时收缩压（SBP）≤90 mmHg。还确定了死亡原因和时间。连续数据以中位数（四分位间距[IQR]）表示。
结果
1706例患者接受了紧急创伤剖腹手术。该队列主要为年轻人（31岁；IQR，24 - 45），男性（84%），遭受钝性创伤（67%），且损伤程度为中度（损伤严重度评分，19；IQR，10 - 33）。在急诊科停留时间为24分钟（IQR，14 - 39），从急诊科入院到手术开始时间为42分钟（IQR，30 - 61）。最常见的手术是肠切除术（23%）、肝缝合术（20%）、肠修补术（16%）和脾切除术（16%）。38%的患者和62%的低血压患者采用了损伤控制剖腹手术。整个队列的损伤严重度评分为19（IQR，10 - 33），低血压组为29（IQR，18 - 41）。整个队列的死亡率为21%，60%的死亡原因是出血。低血压组的死亡率为46%，65%的死亡原因是出血。
结论
创伤剖腹手术的总体死亡率很高（21%），出血占死亡人数的60%。低血压患者的死亡率（46%）在过去二十年中似乎没有变化，甚至更令人担忧，几乎一半收缩压为90 mmHg或更低的患者死亡。
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