抗血小板治疗院前创伤性颅内出血患者的系统评价和荟萃分析：血小板输注是否有作用？
A systematic review and meta-analysis of traumatic intracranial hemorrhage in patients taking prehospital antiplatelet therapy: Is there a role for platelet transfusions?
机构信息
From the Department of Surgery (J.A., S.P.M., M.R.R., M.D.N.), University of Pittsburgh Medical Center; University of Pittsburgh Health Sciences Library System (C.B.W.); Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (B.J.), University of Arizona, Tucson, Arizona; The Iowa Clinic (C.P.), Des Moines, Iowa; Warren Alpert Medical School of Brown University (C.D.), Providence, Rhode Island; Division of Neurological Surgery (A.R.G.), University of Missouri School of Medicine, Columbia, Missouri; and Department of Critical Care Medicine (M.R.R., M.D.N.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
出版信息
J Trauma Acute Care Surg. 2020 Jun;88(6):847-854. doi: 10.1097/TA.0000000000002640.
BACKGROUND
Platelet transfusion has been utilized to reverse platelet dysfunction in patients on preinjury antiplatelets who have sustained a traumatic intracranial hemorrhage (tICH); however, there is little evidence to substantiate this practice. The objective of this study was to perform a systematic review on the impact of platelet transfusion on survival, hemorrhage progression and need for neurosurgical intervention in patients with tICH on prehospital antiplatelet medication.
METHODS
Controlled, observational and randomized, prospective and retrospective studies describing tICH, preinjury antiplatelet use, and platelet transfusion reported in PubMed, Embase, Cochrane Reviews, Cochrane Trials and Cochrane DARE databases between January 1987 and March 2019 were included. Investigations of concomitant anticoagulant use were excluded. Risk of bias was assessed using the Newcastle-Ottawa scale. We calculated pooled estimates of relative effect of platelet transfusion on the risk of death, hemorrhage progression and need for neurosurgical intervention using the methods of Dersimonian-Laird random-effects meta-analysis. Sensitivity analysis established whether study size contributed to heterogeneity. Subgroup analyses determined whether antiplatelet type, additional blood products/reversal agents, or platelet function assays impacted effect size using meta-regression.
RESULTS
Twelve of 18,609 screened references were applicable to our questions and were qualitatively and quantitatively analyzed. We found no association between platelet transfusion and the risk of death in patients with tICH taking prehospital antiplatelets (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.76-2.18; p = 0.346; I = 32.5%). There was no significant reduction in hemorrhage progression (OR, 0.88; 95% CI, 0.34-2.28; p = 0.788; I = 78.1%). There was no significant reduction in the need for neurosurgical intervention (OR, 1.00; 95% CI, 0.53-1.90, p = 0.996; I = 59.1%; p = 0.032).
CONCLUSION
Current evidence does not support the use of platelet transfusion in patients with tICH on prehospital antiplatelets, highlighting the need for a prospective evaluation of this practice.
LEVEL OF EVIDENCE
Systematic Reviews and Meta-Analyses, Level III.
背景
在创伤性颅内出血（tICH）患者中，血小板输注已被用于逆转受伤前使用抗血小板药物的血小板功能障碍；然而，很少有证据支持这种做法。本研究的目的是对在院前使用抗血小板药物的 tICH 患者中，血小板输注对生存、出血进展和需要神经外科干预的影响进行系统评价。
方法
纳入 1987 年 1 月至 2019 年 3 月期间在 PubMed、Embase、Cochrane 综述、Cochrane 试验和 Cochrane DARE 数据库中描述 tICH、受伤前使用抗血小板药物和血小板输注的对照、观察性、随机、前瞻性和回顾性研究。排除同时使用抗凝剂的研究。使用纽卡斯尔-渥太华量表评估偏倚风险。我们使用 Dersimonian-Laird 随机效应荟萃分析方法计算血小板输注对死亡、出血进展和需要神经外科干预风险的相对效应的汇总估计值。敏感性分析确定研究规模是否会导致异质性。亚组分析使用荟萃回归确定抗血小板药物类型、附加血液制品/逆转剂或血小板功能测定是否会影响效应大小。
结果
在筛选的 18609 篇参考文献中，有 12 篇符合我们的问题，并进行了定性和定量分析。我们发现，在接受院前抗血小板药物治疗的 tICH 患者中，血小板输注与死亡风险之间没有关联（比值比[OR]，1.29；95%置信区间[CI]，0.76-2.18；p = 0.346；I = 32.5%）。出血进展没有显著减少（OR，0.88；95% CI，0.34-2.28；p = 0.788；I = 78.1%）。也没有显著减少神经外科干预的需要（OR，1.00；95% CI，0.53-1.90，p = 0.996；I = 59.1%；p = 0.032）。
结论
目前的证据并不支持在院前使用抗血小板药物的 tICH 患者中使用血小板输注，这突出表明需要对这种做法进行前瞻性评估。
证据水平
系统评价和荟萃分析，III 级。
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