比较复苏强度和临界给药阈值对 680 例大出血患者早期死亡率的预测价值：多中心验证。
A comparison of resuscitation intensity and critical administration threshold in predicting early mortality among bleeding patients: A multicenter validation in 680 major transfusion patients.
机构信息
From the University of Texas Health Sciences Center and McGovern School of Medicine (D.E.M., B.A.C., J.B.H.); The Center for Translational Injury Research (B.A.C., J.B.H., E.E.F.), Houston, Texas; The University of Maryland School of Medicine (D.S.), Baltimore, Maryland; The University of Colorado School of Medicine (M.C.), Denver, Colorado; The Keck School of Medicine and Los Angeles County Hospital (K.I.), Los Angeles, California; and The Department of Biomedical Engineering (E.R.), Wake Forest University School of Medicine, Winston-Salem, North Carolina.
出版信息
J Trauma Acute Care Surg. 2018 Oct;85(4):691-696. doi: 10.1097/TA.0000000000002020.
BACKGROUND
To address deficiencies associated with the classic definition of massive transfusion (MT), critical administration threshold (CAT) and resuscitation intensity (RI) were developed to better quantify the overall severity of illness and predict the need for transfusions and early mortality. We sought to evaluate these as more appropriate replacements for MT in defining mortality risk in patients undergoing major transfusions.
METHODS
Patients predicted to receive MT at 12 Level I trauma centers were randomized in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial. MT of 10 U or greater red blood cell (RBC) in 24 hours; CAT+, 3 U or greater RBC in the first hour; and RI, total products in the first 30 minutes (1 U RBC, 1 U plasma, 1000 mL crystalloid, 500 mL colloid each valued at 1 U). Resuscitation intensity was evaluated as a continuous variable and dichotomized as RI4+, where RI is 4 U or greater. Each metric was evaluated for its ability to predict mortality at 3 hours, 6 hours, and 24 hours, and at 30 days.
RESULTS
Of the 680 patients, 301 patients met MT definition, 521 were CAT+, and 445 were RI4+. Of those that died, 23% never reached MT threshold, but all were captured by CAT+ and RI4+. The 3-hour (9% vs. 9%), 6-hour (14% vs. 14%), 24-hour (17% vs. 18%), and 30-day mortality rates (28% vs. 29%) were similar between CAT+ and RI4+ patients. When RI was evaluated as a continuous variable, each unit increase was associated with a 20% increase in hemorrhage-related mortality (odds ratio, 1.20; 95% confidence interval, 1.15-1.29; p < 0.05).
CONCLUSION
Both RI and CAT are valid surrogates for early mortality in patients undergoing major transfusion, capturing patients omitted by the MT definition. The CAT+ showed the best sensitivity; RI4+ demonstrated better specificity and good positive predictive values and negative predictive values. While CAT+ may be suited for patients receiving an RBC-dominant resuscitation, RI4+ is more comprehensive. RI can also be used as a continuous variable to provide quantitative as well as qualitative risk of death.
LEVEL OF EVIDENCE
Prognostic, level III.
背景
为了解决经典大量输血（MT）定义的缺陷，提出了关键输血阈值（CAT）和复苏强度（RI），以更好地量化整体疾病严重程度，并预测输血和早期死亡率的需求。我们试图评估这些作为更合适的替代经典 MT 定义，以确定接受大量输血的患者的死亡风险。
方法
在 12 个一级创伤中心进行的 Pragmatic、Randomized Optimal Platelet and Plasma Ratios（PROPPR）试验中，随机分配预计接受 MT 的患者。MT 定义为 24 小时内输注 10 U 或更多红细胞（RBC）；CAT+定义为 1 小时内输注 3 U 或更多 RBC；RI 定义为前 30 分钟内输注的总产品（1 U RBC、1 U 血浆、1000 mL 晶体液和 500 mL 胶体，每种均计为 1 U）。RI 作为连续变量进行评估，并分为 RI4+，其中 RI 为 4 U 或更高。评估每个指标预测 3 小时、6 小时和 24 小时以及 30 天死亡率的能力。
结果
在 680 名患者中，301 名患者符合 MT 定义，521 名患者为 CAT+，445 名患者为 RI4+。在死亡患者中，23%的患者从未达到 MT 阈值，但所有患者均被 CAT+和 RI4+捕获。3 小时（9%比 9%）、6 小时（14%比 14%）、24 小时（17%比 18%）和 30 天死亡率（28%比 29%）在 CAT+和 RI4+患者之间相似。当 RI 作为连续变量评估时，每增加一个单位，与出血相关的死亡率增加 20%（优势比，1.20；95%置信区间，1.15-1.29；p<0.05）。
结论
RI 和 CAT 都是接受大量输血患者早期死亡率的有效替代指标，可捕获经典 MT 定义中遗漏的患者。CAT+具有最佳的敏感性；RI4+具有更好的特异性和良好的阳性预测值和阴性预测值。虽然 CAT+可能适合接受 RBC 为主的复苏患者，但 RI4+更为全面。RI 也可以用作连续变量，提供定量和定性的死亡风险。
证据水平
预后，III 级。
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