From the Ottawa Hospital Research Institute, Clinical Epidemiology Program (A.T.), University of Ottawa; Division of General Surgery (A.T., J.Y., J.L., M.M.), The Ottawa Hospital, Ottawa, ON; and Department of Anesthesiology (A.L.), University of British Columbia, Vancouver, BC, Canada.
J Trauma Acute Care Surg. 2018 May;84(5):802-808. doi: 10.1097/TA.0000000000001816.
BACKGROUND: Aggressive fluid resuscitation in trauma promotes deleterious effects such as clot disruption, dilutional coagulopathy and hypothermia. Animal studies suggest that permissive hypotension maintains appropriate organ perfusion, reduces bleeding and improves mortality. This review assesses the efficacy and safety of permissive hypotension in adult trauma patients with hemorrhagic shock. METHODS: We searched the MEDLINE and EMBASE databases from inception to May 2017 for randomized controlled trials comparing permissive hypotension vs. conventional resuscitation following traumatic injury. We included preoperative and intraoperative resuscitation strategies. The primary outcome was 30-day or in-hospital mortality. Secondary outcomes included blood product utilization, estimated blood loss and in-hospital complications. Pooling was performed with a random-effects model. RESULTS: We screened 722 abstracts, from which five randomized trials evaluating 1,158 patients were included. Blood pressure targets in the intervention arms varied from systolic BP 50 mm Hg to 70 mm Hg or mean arterial pressure of 50 mm Hg or higher as compared to systolic BP 65 mm Hg to 100 mm Hg or mean arterial pressure of 65 or higher in the control arms. Two studies evaluated only patients with penetrating injury while the remaining three additionally included blunt injuries. Four trials suggested a survival benefit for 30-day or in-hospital mortality with hypotensive resuscitation, although three studies were insufficiently powered to find statistical significance. Studies were of poor to moderate quality due to poor protocol reporting and lack of blinding. The pooled odds ratio was 0.70 (95% confidence interval, 0.53-0.92), suggesting a survival benefit for permissive hypotension. Those patients received fewer blood products and had lesser estimated blood loss. CONCLUSION: Permissive hypotension may offer a survival benefit over conventional resuscitation for patients with hemorrhagic injury. It may additionally reduce blood loss and blood product utilization. However, the majority of studies were underpowered, thus reflecting a need for high quality, adequately powered trials. PROSPERO REGISTRATION: Systematic Review, level II.CRD42017070526.
背景：在创伤中进行积极的液体复苏会导致有害影响，如血栓破坏、稀释性凝血功能障碍和低体温。动物研究表明，允许性低血压可维持适当的器官灌注，减少出血并提高死亡率。本综述评估了允许性低血压在创伤性失血性休克成人患者中的疗效和安全性。
方法：我们从 MEDLINE 和 EMBASE 数据库中检索了从建立到 2017 年 5 月的随机对照试验，比较了创伤后允许性低血压与常规复苏的效果。我们纳入了术前和术中的复苏策略。主要结局为 30 天或住院死亡率。次要结局包括血液制品的使用、估计失血量和住院并发症。采用随机效应模型进行合并。
结果：我们筛选了 722 篇摘要，其中 5 项随机试验评估了 1158 例患者。干预组的血压目标范围从收缩压 50mmHg 到 70mmHg 或平均动脉压 50mmHg 或更高，而对照组的收缩压 65mmHg 到 100mmHg 或平均动脉压 65mmHg 或更高。两项研究仅评估了穿透性损伤患者，而其余三项研究还包括了钝性损伤患者。四项研究表明，低血压复苏可提高 30 天或住院死亡率的生存率，但其中三项研究因样本量不足而未发现统计学意义。由于方案报告不佳和缺乏盲法，这些研究的质量较差或为中等。合并的优势比为 0.70（95%置信区间，0.53-0.92），提示允许性低血压具有生存优势。这些患者使用的血液制品较少，估计失血量也较少。
结论：允许性低血压可能为出血性损伤患者提供优于常规复苏的生存获益。它还可能减少失血和血液制品的使用。然而，大多数研究的样本量不足，因此需要高质量、充分有效的试验。
PROSPERO 注册号：系统评价，二级，CRD42017070526。
Cochrane Database Syst Rev. 2016-5-13
Scand J Trauma Resusc Emerg Med. 2018-12-17
Cochrane Database Syst Rev. 2018-6-13
J Trauma Acute Care Surg. 2012-9
Eur J Trauma Emerg Surg. 2025-8-11
Cardiovasc Drugs Ther. 2025-7-7
BJA Educ. 2025-1
Biomedicines. 2024-12-19
Zotero 插件