Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.
Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
Ann Surg. 2021 Feb 1;273(2):358-364. doi: 10.1097/SLA.0000000000003324.
The aim of this study was to determine whether prehospital blood products reduce 30-day mortality in patients at risk for hemorrhagic shock compared with crystalloid only resuscitation.
Hemorrhage is the primary cause of preventable death after injury. Large volume crystalloid resuscitation can be deleterious. The benefits of prehospital packed red blood cells (PRBCs), plasma, or transfusion of both products among trauma patients is unknown compared with crystalloid.
Secondary analysis of the multicenter PAMPer trial was performed on hypotensive injured patients from the scene. The trial randomized 27 helicopter bases to prehospital plasma or standard resuscitation. Standard resuscitation at the sites was equally divided between crystalloid and crystalloid + PRBC. This led to 4 prehospital resuscitation groups: crystalloid only; PRBC; plasma; and PRBC+plasma. Cox regression determined the association between resuscitation groups and risk-adjusted 30-day mortality. The dose effect of resuscitation fluids was also explored.
Four hundred seven patients were included. PRBC+plasma had the greatest benefit [hazard ratio (HR) 0.38; 95% confidence interval (95% CI) 0.26-0.55, P < 0.001], followed by plasma (HR 0.57; 95% CI 0.36-0.91, P = 0.017) and PRBC (HR 0.68; 95% CI 0.49-0.95, P = 0.025) versus crystalloid only. Mortality was lower per-unit of PRBC (HR 0.69; 95% CI 0.52-0.92, p = 0.009) and plasma (HR 0.68; 95% CI 0.54-0.88, P = 0.003). Crystalloid volume was associated with increased mortality among patients receiving blood products (HR 1.65; 95% CI 1.17-2.32, P = 0.004).
Patients receiving prehospital PRBC+plasma had the greatest mortality benefit. Crystalloid only had the worst survival. Patients with hemorrhagic shock should receive prehospital blood products when available, preferably PRBC+plasma. Prehospital whole blood may be ideal in this population.
本研究旨在确定与仅晶体复苏相比，院前血制品是否可降低出血性休克高危患者 30 天死亡率。
出血是创伤后可预防死亡的主要原因。大量晶体液复苏可能有害。与晶体液相比，院前输注浓缩红细胞（PRBC）、血浆或两者联合对创伤患者的益处尚不清楚。
对多中心 PAMPer 试验中来自现场的低血压受伤患者进行二次分析。该试验将 27 个直升机基地随机分为院前血浆组或标准复苏组。现场的标准复苏同样分为晶体液和晶体液+PRBC。这导致了 4 种院前复苏组：仅晶体液；PRBC；血浆；和 PRBC+血浆。Cox 回归确定复苏组与风险调整后 30 天死亡率之间的关联。还探索了复苏液的剂量效应。
共纳入 407 例患者。PRBC+血浆具有最大的获益[风险比（HR）0.38；95%置信区间（95%CI）0.26-0.55，P<0.001]，其次是血浆（HR 0.57；95%CI 0.36-0.91，P=0.017）和 PRBC（HR 0.68；95%CI 0.49-0.95，P=0.025）与仅晶体液相比。每单位 PRBC（HR 0.69；95%CI 0.52-0.92，P=0.009）和血浆（HR 0.68；95%CI 0.54-0.88，P=0.003）输注，死亡率均降低。晶体液体积与接受血液制品患者的死亡率增加相关（HR 1.65；95%CI 1.17-2.32，P=0.004）。
院前输注 PRBC+血浆的患者死亡率获益最大。仅晶体液复苏的生存最差。出血性休克患者应在有条件时接受院前血液制品，最好是 PRBC+血浆。在该人群中，院前全血可能是理想的选择。
