Foster John C, Sappenfield Joshua W, Smith Robert S, Kiley Sean P
From the University of Florida College of Medicine, Gainesville, Florida.
Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida.
Anesth Analg. 2017 Dec;125(6):2045-2055. doi: 10.1213/ANE.0000000000002436.
The advent of massive transfusion protocols (MTP) has had a significant positive impact on hemorrhaging trauma patient morbidity and mortality. Nevertheless, societal MTP guidelines and individual MTPs at academic institutions continue to circulate opposing recommendations on topics critical to MTPs. This narrative review discusses up-to-date information on 2 such topics, the initiation and termination of an MTP. The discussion for each begins with a review of the recommendations and supporting literature presented by MTP guidelines from 3 prominent societies, the American Society of Anesthesiologists, the American College of Surgeons, and the task force for Advanced Bleeding Care in Trauma. This is followed by an in-depth analysis of the main components within those recommendations. Societal recommendations on MTP initiation in hemorrhaging trauma patients emphasize the use of retrospectively validated massive transfusion (MT) prediction score, specifically, the Assessment of Blood Consumption and Trauma-Associated Severe Hemorrhage scores. Validation studies have shown that both scoring systems perform similarly. Both scores reliably identify patients that will not require an MT, while simultaneously overpredicting MT requirements. However, each scoring system has its unique advantages and disadvantages, and this review discusses how specific aspects of each scoring system can affect widespread applicability and statistical performance. In addition, we discuss the often overlooked topic of initiating MT in nontrauma patients and the specific tools physicians have to guide the MT initiation decision in this unique setting. Despite the serious complications that can arise with transfusion of large volumes of blood products, there is considerably less research pertinent to the topic of MTP termination. Societal recommendations on MTP termination emphasize applying clinical reasoning to identify patients who have bleeding source control and are adequately resuscitated. This review, however, focuses primarily on the recommendations presented by the Advanced Bleeding Care in Trauma's MTP guidelines that call for prompt termination of the algorithm-guided model of resuscitation and rapidly transitioning into a resuscitation model guided by laboratory test results. We also discuss the evidence in support of laboratory result-guided resuscitation and how recent literature on viscoelastic hemostatic assays, although limited, highlights the potential to achieve additional benefits from this method of resuscitation.
大量输血方案（MTP）的出现对出血性创伤患者的发病率和死亡率产生了重大的积极影响。然而，社会层面的MTP指南以及学术机构的个体化MTP在对MTP至关重要的主题上仍存在相互矛盾的建议。本叙述性综述讨论了关于MTP的两个此类主题的最新信息，即MTP的启动和终止。每个主题的讨论首先回顾了美国麻醉医师协会、美国外科医师学会以及创伤高级出血护理工作组这三个著名学会的MTP指南所提出的建议及支持文献。随后对这些建议中的主要内容进行了深入分析。社会层面关于出血性创伤患者启动MTP的建议强调使用经过回顾性验证的大量输血（MT）预测评分，具体而言，即血液消耗评估和创伤相关严重出血评分。验证研究表明，这两种评分系统的表现相似。两种评分都能可靠地识别出不需要大量输血的患者，同时又会过度预测大量输血的需求。然而，每个评分系统都有其独特的优缺点，本综述讨论了每个评分系统的具体方面如何影响广泛适用性和统计性能。此外，我们还讨论了在非创伤患者中启动大量输血这一常被忽视的主题，以及医生在这一独特情况下用于指导大量输血启动决策的具体工具。尽管大量输注血液制品可能会引发严重并发症，但与MTP终止主题相关的研究要少得多。社会层面关于MTP终止的建议强调运用临床推理来识别出血源已得到控制且复苏充分的患者。然而，本综述主要关注创伤高级出血护理的MTP指南所提出的建议，该指南要求迅速终止算法指导的复苏模式，并迅速过渡到由实验室检查结果指导的复苏模式。我们还讨论了支持实验室检查结果指导复苏的证据，以及关于粘弹性止血测定的最新文献，尽管其有限，但凸显了通过这种复苏方法获得额外益处的潜力。
