Taylor John R, Fox Erin E, Holcomb John B, Rizoli Sandro, Inaba Kenji, Schreiber Martin A, Brasel Karen, Scalea Thomas M, Wade Charles E, Bulger Eileen, Cotton Bryan A
From the University of Texas Health Science Center at Houston (J.R.T., E.E.F., J.B.H., C.E.W., B.A.C.), Houston, TX; St. Michael's Hospital-University of Toronto (S.R.), Toronto, ON; University of Southern California (K.I.), Los Angeles, CA; Oregon Health and Science University (M.A.S.), Portland, OR; Medical College of Wisconsin (K.B.), Milwaukee, WI; R Adams Cowley Shock Trauma Center (T.M.S.), University of Maryland Medical Center, Baltimore, MD; University of Washington (E.B.), Seattle, WA.
J Trauma Acute Care Surg. 2018 Jan;84(1):25-30. doi: 10.1097/TA.0000000000001699.
Among bleeding patients, we hypothesized that the hyperfibrinolytic (HF) phenotype would be associated with the highest mortality, whereas shutdown (SD) patients would have the greatest complication burden.
Severely injured patients predicted to receive a massive transfusion at 12 Level I trauma centers were randomized to one of two transfusion ratios as described in the Pragmatic, Randomized, Optimal Platelet and Plasma Ratio trial. Fibrinolysis phenotypes were determined based on admission clot lysis at 30 minutes (LY30): SD ≤0.8%, physiologic (PHYS) 0.9-2.9%, and HF ≥3%. Univariate and multivariate analysis was performed. Logistic regression was used to adjust for age, gender, arrival physiology, shock, injury severity, center effect, and treatment arm.
Among the 680 patients randomized, 547(80%) had admission thrombelastography (TEG) values available to determine fibrinolytic phenotypes. Compared to SD and PHYS, HF patients had higher Injury Severity Score (25 vs. 25 vs. 34), greater base deficit (-8 vs. -6 vs. -12) and were more uniformly hypocoagulable on admission by PT, PTT, and TEG values; all p <0.001. HF patients also received more red blood cells, plasma, and platelets (at 3, 6, and 24 hours); had fewer ICU-, ventilator-, and hospital-free days; and had higher 24-hour and 30-day mortality. There were no differences in complications between the three phenotypes. Multivariate logistic regression demonstrated that HF on admission was associated with a threefold higher mortality (OR 3.06, 95% CI 1.57-5.95, p = 0.001).
Previous data have shown that both the SD and HF phenotypes are associated with increased mortality and complications in the general trauma population. However, in a large cohort of bleeding patients, HF was confirmed to be a much more lethal and resource-intense phenotype. These data suggest that further research into the understanding of SD and HF is warranted to improve outcomes in this patient population.
Prognostic, level II.
在出血患者中，我们假设高纤溶（HF）表型与最高死亡率相关，而止血关闭（SD）患者的并发症负担最重。
预计在12家一级创伤中心接受大量输血的重伤患者被随机分为两种输血比例之一，如实用、随机、最佳血小板与血浆比例试验中所述。根据入院时30分钟的血凝块溶解情况（LY30）确定纤溶表型：SD≤0.8%，生理性（PHYS）0.9 - 2.9%，HF≥3%。进行单因素和多因素分析。采用逻辑回归调整年龄、性别、入院时生理状态、休克、损伤严重程度、中心效应和治疗组。
在680例随机分组的患者中，547例（80%）有入院血栓弹力图（TEG）值可用于确定纤溶表型。与SD和PHYS患者相比，HF患者的损伤严重程度评分更高（分别为25、25和34），碱缺失更大（分别为 - 8、 - 6和 - 12），入院时PT、PTT和TEG值显示其凝血功能更一致地处于低凝状态；所有p<0.001。HF患者还接受了更多的红细胞、血浆和血小板（在3、6和24小时）；无ICU、无呼吸机和无住院天数更少；24小时和30天死亡率更高。三种表型在并发症方面无差异。多因素逻辑回归显示入院时HF与死亡率高三倍相关（OR 3.06，95%CI 1.57 - 5.95，p = 0.001）。
先前的数据表明，SD和HF表型在一般创伤人群中均与死亡率和并发症增加相关。然而，在一大群出血患者中，HF被证实是一种更具致死性且资源消耗大的表型。这些数据表明，有必要进一步研究以了解SD和HF，从而改善该患者群体的预后。
预后性，二级。
