低温对大量输血患者结局的影响。
The impact of hypothermia on outcomes in massively transfused patients.
机构信息
From the Division of General Surgery (E.L.W.L.), Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Center for Translational Injury Research (E.E.F., J.H.), Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston, Texas; Division of Trauma (K.B.), Critical Care and Acute Care Surgery, School of Medicine, Oregon Health and Science University, Portland, Oregon; Division of Trauma and Critical Care (E.M.B.), Department of Surgery, School of Medicine, University of Washington, Seattle, Washington; Department of Surgery (M.C.), University of Colorado, Denver, Colorado; Center for Translational Injury Research (B.A.C.), Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston, Texas; Division of Trauma and Surgical Critical Care (T.C.T.C.F.), Department of Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; Division of Trauma (J.D.K.), Burns and Surgical Critical Care, Department of Surgery, School of Medicine, University of Alabama, Birmingham, Alabama; Division of Trauma (T.O.), Critical Care and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona; Trauma and Acute Care Service (S.B.R.), St. Michael's Hospital, Toronto, Ontario, Canada; R Adams Crowley Shock Trauma Center (T.S.), University of Maryland, Baltimore, Maryland; Division of Trauma (M.A.S.), Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon; and Division of Trauma and Critical Care (K.I.), LAC+USC Medical Center, University of Southern California, Los Angeles, California.
出版信息
J Trauma Acute Care Surg. 2019 Mar;86(3):458-463. doi: 10.1097/TA.0000000000002144.
BACKGROUND
Hypothermia is associated with poor outcomes after injury. The relationship between hypothermia during contemporary large volume resuscitation and blood product consumption is unknown. We evaluated this association, and the predictive value of hypothermia on mortality.
METHODS
Patients predicted to receive massive transfusion at 12 level 1 trauma centers were randomized in the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial and were grouped into those who were hypothermic (<36°C) or normothermic (36-38.5°C) within the first 6 hours of emergency department arrival. The impact of hypothermia or normothermia on the volume of blood product required during the first 24 hours was determined via negative binomial regression, adjusting for treatment arm, injury severity score, mechanism, demographics, pre-emergency department fluid volume, blood administered before becoming hypothermic, pulse and systolic blood pressure on arrival, and the time exposed to hypothermic or normothermic temperatures.
RESULTS
Of 680 patients, 590 had a temperature measured during the first 6 hours in hospital, and 399 experienced hypothermia. The mean number of red blood cell (RBC) units given to all patients in the first 24 hours of admission was 8.8 (95% confidence interval [CI], 7.9-9.6). In multivariable analysis, every 1°C decrease in temperature below 36.0°C was associated with a 10% increase (incidence rate ratio, 0.90; 95% CI, 0.89-0.92; p < 0.00) in consumption of RBCs during the first 24 hours of admission. There was no association between RBC administration and a temperature above 36°C. Hypothermia on arrival was an independent predictor of mortality, with an adjusted odds ratio of 2.7 (95% CI, 1.7-4.5; p < 0.00) for 24-hour mortality and 1.8 (95% CI, 1.3-2.4; p < 0.00) for 30-day mortality.
CONCLUSION
Hypothermia is associated with increase in blood product consumption and mortality. These findings support the maintenance of normothermia in trauma patients and suggest that further investigation on the impact of cooling or rewarming during massive transfusion is warranted.
LEVEL OF EVIDENCE
Prognostic, level III.
背景
体温过低与受伤后预后不良有关。目前尚不清楚在当代大量液体复苏过程中体温过低与血液制品消耗之间的关系。我们评估了这种相关性，以及体温过低对死亡率的预测价值。
方法
在 12 个 1 级创伤中心，预计将接受大量输血的患者在 Pragmatic Randomized Optimal Platelet and Plasma Ratios（PROPPR）试验中进行了随机分组，并分为在急诊科到达后 6 小时内体温过低（<36°C）或体温正常（36-38.5°C）的患者。通过负二项回归确定体温过低或体温正常对前 24 小时内所需血液制品量的影响，调整处理臂、损伤严重程度评分、机制、人口统计学、急诊前液体量、体温过低前给予的血液量、到达时的脉搏和收缩压，以及暴露于体温过低或体温正常温度下的时间。
结果
在 680 名患者中，590 名患者在住院的前 6 小时内测量了体温，399 名患者出现体温过低。所有患者在前 24 小时内接受的红细胞（RBC）单位数平均为 8.8（95%置信区间[CI]，7.9-9.6）。在多变量分析中，体温每降低 1°C（36.0°C 以下），入院后前 24 小时内 RBC 消耗增加 10%（发病率比，0.90；95%CI，0.89-0.92；p < 0.00）。体温高于 36°C 与 RBC 给药无关联。入院时体温过低是死亡率的独立预测因素，24 小时死亡率的调整比值比为 2.7（95%CI，1.7-4.5；p < 0.00），30 天死亡率的调整比值比为 1.8（95%CI，1.3-2.4；p < 0.00）。
结论
体温过低与血液制品消耗增加和死亡率增加有关。这些发现支持在创伤患者中保持正常体温，并表明需要进一步研究在大量输血期间冷却或复温的影响。
证据水平
预后，III 级。
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