血流动力学不稳定创伤患者“黄金一小时”的修订：基于日本全国医院登记处的分析
Revision of 'golden hour' for hemodynamically unstable trauma patients: an analysis of nationwide hospital-based registry in Japan.
作者信息
Okada Kazuhiro, Matsumoto Hisashi, Saito Nobuyuki, Yagi Takanori, Lee Mihye
机构信息
Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan.
School of Public Health, St Luke's International University, Tokyo, Japan.
出版信息
Trauma Surg Acute Care Open. 2020 Mar 10;5(1):e000405. doi: 10.1136/tsaco-2019-000405. eCollection 2020.
BACKGROUND
The 'golden hour' is a well-known concept, suggesting that shortening time from injury to definitive care is critically important for better outcome of trauma patients. However, there was no established evidence to support it. We aimed to validate the association between time to definitive care and mortality in hemodynamically unstable patients for the current trauma care settings.
METHODS
The data were collected from the Japan Trauma Data Bank between 2006 and 2015. The inclusion criteria were patients with systolic blood pressure (SBP) <90 mm Hg and heart rate (HR) >110 beats/min or SBP <70 mm Hg who underwent definitive care within 4 hours from the onset of injury and survived for more than 4 hours. The outcome measure was in-hospital mortality. We evaluated the relationship between time to definitive care and mortality using the generalized additive model (GAM). Subgroup analysis was also conducted using GAM after dividing the patients into the severe (SBP <70 mm Hg) and moderate (SBP ≥70 mm Hg and <90 mm Hg, and HR >110 beats/min) shock group.
RESULTS
1169 patients were enrolled in this study. Of these, 386 (33.0%) died. Median time from injury to definitive care was 137 min. Only 61 patients (5.2%) received definitive care within 60 min. The GAM models demonstrated that mortality remained stable for the early phase, followed by a decrease over time. The severe shock group presented with a paradoxical decline of mortality with time, whereas the moderate shock group had a time-dependent increase in mortality.
DISCUSSION
We did not observe the association of shorter time to definitive care with a decrease in mortality. However, this was likely an offset result of severe and moderate shock groups. The result indicated that early definitive care could have a positive impact on survival outcome of patients with moderate shock.
LEVEL OF EVIDENCE
Level Ⅳ, prognostic study.
背景
“黄金一小时”是一个广为人知的概念，表明缩短从受伤到确定性治疗的时间对于改善创伤患者的预后至关重要。然而，尚无确凿证据支持这一观点。我们旨在验证在当前创伤治疗环境下，血流动力学不稳定患者获得确定性治疗的时间与死亡率之间的关联。
方法
数据收集自2006年至2015年的日本创伤数据库。纳入标准为收缩压（SBP）<90 mmHg且心率（HR）>110次/分钟或SBP<70 mmHg的患者，这些患者在受伤后4小时内接受了确定性治疗且存活超过4小时。结局指标为院内死亡率。我们使用广义相加模型（GAM）评估获得确定性治疗的时间与死亡率之间的关系。在将患者分为重度（SBP<70 mmHg）和中度（SBP≥70 mmHg且<90 mmHg，HR>110次/分钟）休克组后，也使用GAM进行亚组分析。
结果
本研究共纳入1169例患者。其中，386例（33.0%）死亡。从受伤到确定性治疗的中位时间为137分钟。只有61例患者（5.2%）在60分钟内接受了确定性治疗。GAM模型显示，死亡率在早期保持稳定，随后随时间下降。重度休克组死亡率随时间呈反常下降，而中度休克组死亡率随时间呈依赖性增加。
讨论
我们未观察到获得确定性治疗时间缩短与死亡率降低之间的关联。然而，这可能是重度和中度休克组相互抵消的结果。结果表明，早期确定性治疗可能对中度休克患者的生存结局产生积极影响。
证据级别
Ⅳ级，预后研究。
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