Anesthesia Associates of Willimantic, P.C., Willimantic, CT 06226, United States.
Western Reserve Hospital, Ohio University, Cuyahoga Falls, OH 44233, United States.
J Clin Anesth. 2018 Feb;44:50-56. doi: 10.1016/j.jclinane.2017.10.003. Epub 2017 Nov 7.
Study Objective. To compare the clinical outcomes of patients with severe postpartum hemorrhage (PPH) managed with and without the use of Point-of-Care Viscoelastic Testing (PCVT) to direct blood product replacement. Design. A retrospective cohort study of consecutive cases of severe PPH managed at a single tertiary care center between January 1, 2011 and July 31, 2015. Cases included patients managed using PCVT. Controls were patients managed using a standardized massive hemorrhage transfusion protocol, either because PCVT was not yet available or because no PCVT credentialed providers were on site. Setting. Delivery room, postoperative recovery area, intensive care unit. Patients. There were 6,708 cesarean deliveries and 13,641 vaginal births during the study period. Eighty six patients (0.4% of all deliveries) developed severe PPH. Severe PPH occurred in 1% (68/6,708) of cesarean and 0.1% (18/13,641) of vaginal deliveries. Twenty-eight of these 86 patients (32.6%) were managed with PCVT and 58 (67.4%) without PCVT. Interventions. Patients with severe PPH were managed according to a standardized massive transfusion protocol or a PCVT-based protocol to direct blood product replacement. Measurements. PCVT testing was performed using a ROTEM delta device. Results. Patients in the PCVT cohort received significantly fewer transfusions of packed red blood cells, fresh frozen plasma, and platelet concentrates. They also had a significantly lower estimated blood loss, and a significantly lower incidence of cesarean hysterectomy and postoperative ICU admission as compared with patients not managed using PCVT. The length of postpartum hospitalization was also significantly shorter in the PCVT cohort. Among patients who gave birth within 24 hours of admission, the direct cost of hospitalization was 40% lower for patients in the PCVT cohort. Conclusions. PCVT-based goal-directed blood product replacement management was associated with substantial benefits over a standardized massive transfusion protocol both in terms of patient outcomes and cost of care.
研究目的。比较使用即时凝血弹性测试（Point-of-Care Viscoelastic Testing，PCVT）和不使用即时凝血弹性测试指导血制品替代治疗的严重产后出血（Postpartum Hemorrhage，PPH）患者的临床结局。设计。回顾性队列研究，纳入 2011 年 1 月 1 日至 2015 年 7 月 31 日期间在单家三级保健中心治疗的严重 PPH 连续病例。病例包括使用 PCVT 治疗的患者。对照组为使用标准化大出血输血方案治疗的患者，或者因为尚未使用 PCVT，或者因为没有 PCVT 认证的提供者在场。地点。分娩室、术后恢复区、重症监护病房。患者。研究期间共有 6708 例剖宫产和 13641 例阴道分娩。86 例（所有分娩的 0.4%）发生严重 PPH。严重 PPH 发生在 1%（68/6708）剖宫产和 0.1%（18/13641）阴道分娩中。这些患者中有 28 例（32.6%）采用 PCVT 治疗，58 例（67.4%）未采用 PCVT 治疗。干预措施。严重 PPH 患者根据标准化大量输血方案或基于 PCVT 的方案进行管理，以指导血制品替代。测量。使用 ROTEM delta 设备进行 PCVT 检测。结果。PCVT 组患者接受的浓缩红细胞、新鲜冷冻血浆和血小板浓缩物输注明显减少。与未使用 PCVT 治疗的患者相比，他们的估计出血量明显减少，剖宫产子宫切除术和术后 ICU 入院的发生率明显降低。PCVT 组患者的产后住院时间也明显缩短。在入院后 24 小时内分娩的患者中，PCVT 组患者的住院直接费用降低了 40%。结论。与标准化大量输血方案相比，基于 PCVT 的目标导向血制品替代管理在患者结局和护理成本方面均具有显著优势。
