Kumar Monisha A, Levine Joshua, Faerber Jennifer, Elliott J Paul, Winn H Richard, Doerfler Sean, Le Roux Peter
Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
World Neurosurg. 2017 Dec;108:807-816. doi: 10.1016/j.wneu.2017.09.038. Epub 2017 Oct 14.
The optimal red blood cell transfusion (RBCT) trigger for patients with aneurysmal subarachnoid hemorrhage (SAH) is unknown. In patients with cerebral vasospasm, anemia may increase susceptibility to ischemic injury; conversely, RBCT may worsen outcome given known deleterious effects.
To examine the association between RBCT, delayed cerebral ischemia (DCI), vasospasm, and outcome after SAH.
A total of 421 consecutive patients with SAH, admitted to a neurocritical care unit at a university-affiliated hospital and who underwent surgical occlusion of their ruptured aneurysm were retrospectively identified from a prospective observational database. Propensity score methods were used to reduce the bias associated with treatment selection.
Two hundred and sixty-one patients (62.0%) received an RBCT. Angiographic vasospasm (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.1-2.3; P = 0.025) but not severe angiographic spasm, DCI, or delayed infarction was associated with RBCT. A total of 283 patients (67.2%) experienced a favorable outcome, defined as good or moderately disabled on the Glasgow Outcome Scale; 47 (11.2%) were severely disabled or vegetative and 91 patients (21.6%) were dead at 6-month follow-up. Among patients who survived ≥2 days, RBCT was associated with unfavorable outcome (OR, 2.6; 95% CI, 1.6-4.1). Transfusion of ≥3 units of blood was associated with an increased incidence of unfavorable outcome. Propensity analysis to control for the probability of exposure to RBCT conditional on observed covariates measured before RBCT indicates that RBCT is associated with unfavorable outcome in the absence of DCI (OR, 2.17; 95% CI, 1.56-3.01; P < 0.0001) but not when DCI is present (OR, 0.82; 95% CI, 0.35-1.92; P = 0.65).
Blood transfusions are associated with unfavorable outcome after SAH particularly when DCI is absent. Propensity analysis suggests that RBCT may be associated with poor outcome rather than being a marker of disease severity. However, when DCI is present, RBCT may help improve outcome.
动脉瘤性蛛网膜下腔出血（SAH）患者的最佳红细胞输血（RBCT）触发阈值尚不清楚。在脑血管痉挛患者中，贫血可能会增加缺血性损伤的易感性；相反，鉴于已知的有害影响，RBCT可能会使预后恶化。
研究RBCT、延迟性脑缺血（DCI）、血管痉挛与SAH后预后之间的关联。
从一个前瞻性观察数据库中回顾性识别出421例连续的SAH患者，这些患者均入住一所大学附属医院的神经重症监护病房，并接受了破裂动脉瘤的手术夹闭。采用倾向评分方法以减少与治疗选择相关的偏倚。
261例患者（62.0%）接受了RBCT。血管造影显示血管痉挛（优势比[OR] 1.6；95%置信区间[CI]，1.1 - 2.3；P = 0.025）与RBCT相关，但严重血管造影痉挛、DCI或延迟性梗死与RBCT无关。共有283例患者（67.2%）获得了良好的预后，定义为格拉斯哥预后量表评分为良好或中度残疾；47例（11.2%）为严重残疾或植物状态，91例患者（21.6%）在6个月随访时死亡。在存活≥2天的患者中，RBCT与不良预后相关（OR，2.6；95% CI，1.6 - 4.1）。输注≥3单位血液与不良预后发生率增加相关。基于RBCT前测量的观察协变量对暴露于RBCT的概率进行控制的倾向分析表明，在没有DCI的情况下，RBCT与不良预后相关（OR，2.17；95% CI，1.56 - 3.01；P < 0.0001），但在存在DCI时则不然（OR，0.82；95% CI，0.35 - 1.92；P = 0.65）。
SAH后输血与不良预后相关，尤其是在没有DCI的情况下。倾向分析表明，RBCT可能与不良预后相关，而不是疾病严重程度的标志物。然而，当存在DCI时，RBCT可能有助于改善预后。
