预测创伤后急性呼吸窘迫综合征的因素：止血复苏时代肺损伤仍然存在。
Predictors of postinjury acute respiratory distress syndrome: Lung injury persists in the era of hemostatic resuscitation.
机构信息
From the Department of Surgery (L.Z.K., A.J.R., A.S.C., B.J.R., B.M.H., M.F.N.), Zuckerberg San Francisco General Hospital and the University of California, San Francisco, San Francisco, California; Department of Medicine (C.M.H., C.S.C.), University of California, San Francisco, San Francisco, California; Department of Biostatistics (S.M.), University of California, Berkeley, Berkeley, California; and Department of Surgery (M.J.C.), Denver Health Medical Center and the University of Colorado, Denver, Colorado.
出版信息
J Trauma Acute Care Surg. 2019 Aug;87(2):371-378. doi: 10.1097/TA.0000000000002331.
BACKGROUND
Acute respiratory distress syndrome (ARDS) following trauma is historically associated with crystalloid and blood product exposure. Advances in resuscitation have occurred over the last decade, but their impact on ARDS is unknown. We sought to investigate predictors of postinjury ARDS in the era of hemostatic resuscitation.
METHODS
Data were prospectively collected from arrival to 28 days for 914 highest-level trauma activations who required intubation and survived more than 6 hours from 2005 to 2016 at a Level I trauma center. Patients with ratio of partial pressure of oxygen to fraction of inspired oxygen of 300 mmHg or less during the first 8 days were identified. Two blinded expert clinicians adjudicated all chest radiographs for bilateral infiltrates in the first 8 days. Those with left-sided heart failure detected were excluded. Multivariate logistic regression was used to define predictors of ARDS.
RESULTS
Of the 914 intubated patients, 63% had a ratio of partial pressure of oxygen to fraction of inspired oxygen of 300 or less, and 22% developed ARDS; among the ARDS cases, 57% were diagnosed early (in the first 24 hours), and 43% later. Patients with ARDS diagnosed later were more severely injured (ISS 32 vs. 20, p = 0.001), with higher rates of blunt injury (84% vs. 72%, p = 0.008), chest injury (58% vs. 36%, p < 0.001), and traumatic brain injury (72% vs. 48%, p < 0.001) compared with the no ARDS group. In multivariate analysis, head/chest Abbreviated Injury Score scores, crystalloid from 0 to 6 hours, and platelet transfusion from 0 to 6 hours and 7 to 24 hours were independent predictors of ARDS developing after 24 hours.
CONCLUSIONS
Blood and plasma transfusion were not independently associated with ARDS. However, platelet transfusion was a significant independent risk factor. The role of platelets warrants further investigation but may be mechanistically explained by lung injury models of pulmonary platelet sequestration with peripheral thrombocytopenia.
LEVEL OF EVIDENCE
Prognostic study, level IV.
背景
创伤后急性呼吸窘迫综合征（ARDS）传统上与晶体液和血制品的使用有关。在过去十年中，复苏技术取得了进展，但它们对 ARDS 的影响尚不清楚。我们旨在研究止血复苏时代创伤后 ARDS 的预测因素。
方法
2005 年至 2016 年，在一家一级创伤中心，对需要插管且从发病到 6 小时以上存活的 914 名最高级别创伤激活患者，从到达到 28 天进行前瞻性数据采集。在最初的 8 天内，识别出氧分压与吸入氧分数比值为 300mmHg 或更低的患者。两名盲法专家临床医生对最初 8 天内所有双侧浸润性胸部 X 线片进行裁决。排除左侧心力衰竭的患者。多变量逻辑回归用于定义 ARDS 的预测因素。
结果
在 914 名插管患者中，63%的患者氧分压与吸入氧分数比值为 300mmHg 或更低，22%的患者发生 ARDS；在 ARDS 病例中，57%为早期诊断（24 小时内），43%为晚期诊断。较晚诊断为 ARDS 的患者损伤更严重（ISS 32 比 20，p=0.001），钝性损伤发生率较高（84%比 72%，p=0.008），胸部损伤发生率较高（58%比 36%，p<0.001），创伤性脑损伤发生率较高（72%比 48%，p<0.001）。多变量分析显示，头部/胸部简明损伤评分、0 至 6 小时晶体液以及 0 至 6 小时和 7 至 24 小时血小板输注是 24 小时后 ARDS 发生的独立预测因素。
结论
血液和血浆的输注与 ARDS 并无独立关联。然而，血小板输注是一个显著的独立危险因素。血小板的作用需要进一步研究，但可能通过肺部血小板隔离和外周血小板减少的肺血小板隔离的肺损伤模型得到解释。
证据等级
预后研究，IV 级。
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