Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA.
Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA.
J Am Coll Surg. 2019 Aug;229(2):184-191. doi: 10.1016/j.jamcollsurg.2019.03.021. Epub 2019 May 16.
Hypotension based on low systolic blood pressure (SBP) is a well-documented indicator of ongoing blood loss. However, the utility of pulse pressure (PP) for detection of hemorrhage has not been well studied. The purpose of this study was to determine whether a narrowed PP in nonhypotensive patients is an independent predictor of critical administration threshold (CAT+) hemorrhage requiring surgical or endovascular control.
We performed a retrospective single-center study (January 2010 to October 2014), including trauma patients ≥16 years old with SBP ≥ 90 mmHg upon emergency department (ED) admission. We identified patients who were both CAT+ and required either surgical or interventional radiology for definitive hemorrhage control as the active hemorrhage (AH) group. Analyses were then performed to elucidate the association between PP and hemorrhage.
Of the total 18,015 patients identified, 283 (1.6%) met the criteria for clinically significant hemorrhage. Mean PP was significantly lower in the AH group compared with the non-AH group (39 ± 18 mmHg vs 53 ± 19 mmHg, p < 0.0001). Multivariate analysis revealed that narrowed initial ED PP is an independent predictor of AH (adjusted odds ratio [AOR] 0.975) along with age (AOR 1.01), penetrating mechanism (AOR 9.476), field SBP (AOR 0.985), ED heart rate (AOR 1.024), and Injury Severity Score (AOR 1.126). Cutoff analysis of PP values identified a significantly higher risk of AH at a PP cutoff of 55 mmHg (AOR 3.44, p = 0.005, AUC 0.955) in patients 61 years or older vs 40 mmHg (AOR 2.73, p < 0.0001, AUC 0.940) for patients 16 to 60 years old. The predicted probability of AH increases as PP narrows.
In patients who are nonhypotensive, a narrowed PP is an independent early predictor of active hemorrhage requiring blood product transfusion and intervention for hemorrhage control.
基于较低收缩压（SBP）的低血压是持续失血的一个有充分记录的指标。然而，脉压（PP）对出血检测的作用尚未得到很好的研究。本研究的目的是确定非低血压患者的狭窄 PP 是否是需要手术或血管内控制的关键治疗阈值（CAT+）出血的独立预测因子。
我们进行了一项回顾性单中心研究（2010 年 1 月至 2014 年 10 月），包括急诊科（ED）就诊时 SBP≥90mmHg 的≥16 岁的创伤患者。我们确定了既是 CAT+又需要手术或介入放射学来明确控制出血的患者作为活动性出血（AH）组。然后进行分析以阐明 PP 与出血之间的关系。
在确定的 18015 例患者中，有 283 例（1.6%）符合临床显著出血的标准。与非 AH 组相比，AH 组的平均 PP 明显较低（39±18mmHg 比 53±19mmHg，p<0.0001）。多变量分析显示，初始 ED 的狭窄 PP 是 AH 的独立预测因子（调整后的优势比[OR]0.975），以及年龄（OR 1.01）、穿透机制（OR 9.476）、现场 SBP（OR 0.985）、ED 心率（OR 1.024）和损伤严重程度评分（OR 1.126）。PP 值的截断分析表明，在 61 岁或以上的患者中，PP 截断值为 55mmHg 时，AH 的风险显著增加（OR 3.44，p=0.005，AUC 0.955），而在 16 至 60 岁的患者中，PP 截断值为 40mmHg 时，AH 的风险增加（OR 2.73，p<0.0001，AUC 0.940）。随着 PP 变窄，AH 的预测概率增加。
在非低血压患者中，狭窄的 PP 是需要输血和干预控制出血的活动性出血的独立早期预测因子。
