Shand Sophie, Curtis Kate, Dinh Michael, Burns Brian
Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia; NSW Ambulance, Sydney Ambulance Centre, Eveleigh, NSW, Australia.
Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia; Illawarra Shoalhaven Local Health District, NSW, Australia.
Injury. 2019 Feb;50(2):226-234. doi: 10.1016/j.injury.2018.11.049. Epub 2018 Dec 12.
Catastrophic haemorrhage is recognised as the leading cause of preventable death in trauma and is also prevalent in medical and other surgical aetiology. Prehospital blood product transfusion is increasingly available for both military and civilian emergency teams. Hospitals have well-established massive transfusion protocols for the resuscitation of this patient group, however the use and impact in the prehospital field is less understood.
To identify and evaluate the current knowledge surrounding prehospital blood product administration for patients with catastrophic haemorrhage.
The integrative review method included systematic searching of online databases Medline, EMBASE, SCOPUS and CINAHL alongside hand-searching for primary research articles published prior to 19 November 2018. Papers were included if the population studied patients with catastrophic haemorrhage who received prehospital transfusion of blood products. The level of evidence and quality was evaluated using the NHMRC hierarchy of evidence. All identified full text articles were reviewed by all authors.
Twenty-two papers were included in the final analysis, including both civilian (16) and military (6) practice. The earliest publication for prehospital transfusion was 1999, with increasing prevalence in recent years. Findings were extracted and into two main categories; (1) transfusion processes included team staffing, product selection, and criteria for transfusion and (2) transfusion outcomes; transfusion safety, haemoglobin, hospital intervention and mortality.
The level of evidence specific to prehospital blood product transfusion is low, with predominantly retrospective methods and rarely sufficient sample sizes to reach statistical significance. Prehospital research is challenged by clinical and logistical variability preventing accurate cohort matching, sample sizes and inconsistent data collection. Evaluation of prehospital transfusion in isolation is also particularly problematic as multiple factors and developments in clinical practice affect patient outcomes and all samples were subject to survival bias. Conclusion The volume and strength of the available evidence prevents accurate evaluation of the intervention and definitive practice recommendations however prehospital transfusion is shown to be logistically achievable and without serious incident. The reviewed evidence broadly supports the translation of recent in-hospital studies, such as PROMTT and PROPPR. Further research specific to prehospital practice is required to guide the development of evidence-based protocols.
灾难性出血被认为是创伤中可预防死亡的主要原因，在医学和其他外科病因中也很常见。院前血液制品输血越来越多地可供军事和民用应急团队使用。医院有完善的大量输血方案用于该患者群体的复苏，然而其在院前领域的使用和影响尚鲜为人知。
识别并评估当前关于灾难性出血患者院前血液制品输注的知识。
综合回顾方法包括系统检索在线数据库Medline、EMBASE、SCOPUS和CINAHL，同时手工检索2018年11月19日前发表的原始研究文章。如果研究人群为接受院前血液制品输血的灾难性出血患者，则纳入该论文。使用澳大利亚国家卫生与医学研究委员会（NHMRC）的证据等级体系评估证据水平和质量。所有确定的全文文章均由所有作者进行评审。
最终分析纳入了22篇论文，包括民用（16篇）和军事（6篇）实践。院前输血的最早出版物为1999年，近年来其发生率不断增加。研究结果被提取并分为两个主要类别；（1）输血过程包括团队人员配备、产品选择和输血标准，以及（2）输血结果；输血安全性、血红蛋白、医院干预和死亡率。
院前血液制品输血的具体证据水平较低，主要采用回顾性方法，样本量很少足以达到统计学意义。院前研究受到临床和后勤变异性的挑战，这妨碍了准确的队列匹配、样本量和不一致的数据收集。单独评估院前输血也特别成问题，因为临床实践中的多种因素和进展会影响患者结局，且所有样本都存在生存偏差。结论现有证据的数量和强度妨碍了对该干预措施的准确评估和明确的实践建议，然而院前输血在后勤上是可行的，且无严重事件发生。所审查的证据广泛支持将近期的院内研究，如PROMTT和PROPPR进行转化应用。需要针对院前实践开展进一步研究，以指导循证方案的制定。
