小儿创伤中晶体和血制品的时机和容量：东部创伤外科学会多中心前瞻性观察研究。
Timing and volume of crystalloid and blood products in pediatric trauma: An Eastern Association for the Surgery of Trauma multicenter prospective observational study.
机构信息
From the Division of Pediatric General and Thoracic Surgery (S.F.P., S.M., R.A.F., T.M.J.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Le Bonheur Children's Hospital (R.F.W.), Memphis, Tennessee; College of Medicine (M.L.K.), Florida Atlantic University, Boca Raton, Florida and the Palm Beach Children's Hospital, West Palm Beach, Florida; Children's National Medical Center (E.C.A., R.S.B.), Washington, DC; UCHealth Memorial Hospital (T.J.S.), Colorado Springs, Colorado; Loma Linda University (J.E.B., A.M.), Loma Linda, California; Children's Hospital of Richmond (W.B.R., L.A.B.), Virginia Commonwealth University, Richmond, Virginia; Denver Health Medical Center (E.M.C., C.R.), Denver, Colorado; Hennepin Healthcare (R.M.N., C.J.R.), Minneapolis, Minnesota; The Medical University of South Carolina (D.I.G., C.J.S.), Charleston, South Carolina; Wake Forest Baptist Medical Center (M.G., J.K.P.), Brenner Children's Hospital, Winston-Salem, North Carolina; Children's Health Dallas (C.G., S.P.), Dallas, Texas; Children's of Alabama (A.M.W., R.T.R.), Birmingham, Alabama; College of Medicine (B.K.Y., J.M.), University of Florida-Jacksonville, Jacksonville, Florida; Dayton Children's Hospital (J.P.), Dayton, OH; Children's Healthcare of Atlanta (M.T.S.), Atlanta, Georgia; Mayo Clinic (T.M., D.B.K.), Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota; Carilion Children's Hospital (S.D.S., T.T.), Carilion Roanoke Memorial Hospital, Roanoke, Virginia; Texas Children's Hospital (A.M.V., M.C.), Houston, Texas; ProMedica Toledo and Toledo Children's Hospital (C.B.), Toledo, Ohio; Children's Hospital Los Angeles (J.R., R.G.S., A.R.J.), Los Angeles, California; Boston Children's Hospital (B.J.F., D.P.M.), Boston, Massachusetts; Arkansas Children's Hospital (B.K., M.S.D.), Little Rock, Arkansas; and Cooper University Hospital (A.G.-S., J.S.R.), Camden, New Jersey.
出版信息
J Trauma Acute Care Surg. 2020 Jul;89(1):36-42. doi: 10.1097/TA.0000000000002702.
BACKGROUND
The purpose of this study was to determine the relationship between timing and volume of crystalloid before blood products and mortality, hypothesizing that earlier transfusion and decreased crystalloid before transfusion would be associated with improved outcomes.
METHODS
A multi-institutional prospective observational study of pediatric trauma patients younger than 18 years, transported from the scene of injury with elevated age-adjusted shock index on arrival, was performed from April 2018 to September 2019. Volume and timing of prehospital, emergency department, and initial admission resuscitation were assessed including calculation of 20 ± 10 mL/kg crystalloid boluses overall and before transfusion. Multivariable Cox proportional hazards and logistic regression models identified factors associated with mortality and extended intensive care, ventilator, and hospital days.
RESULTS
In 712 children at 24 trauma centers, mean age was 7.6 years, median (interquartile range) Injury Severity Score was 9 (2-20), and in-hospital mortality was 5.3% (n = 38). There were 311 patients(43.7%) who received at least one crystalloid bolus and 149 (20.9%) who received blood including 65 (9.6%) with massive transfusion activation. Half (53.3%) of patients who received greater than one crystalloid bolus required transfusion. Patients who received blood first (n = 41) had shorter median time to transfusion (19.8 vs. 78.0 minutes, p = 0.005) and less total fluid volume (50.4 vs. 86.6 mL/kg, p = 0.033) than those who received crystalloid first despite similar Injury Severity Score (median, 22 vs. 27, p = 0.40). On multivariable analysis, there was no association with mortality (p = 0.51); however, each crystalloid bolus after the first was incrementally associated with increased odds of extended ventilator, intensive care unit, and hospital days (all p < 0.05). Longer time to transfusion was associated with extended ventilator duration (odds ratio, 1.11; p = 0.04).
CONCLUSION
Resuscitation with greater than one crystalloid bolus was associated with increased need for transfusion and worse outcomes including extended duration of mechanical ventilation and hospitalization in this prospective study. These data support a crystalloid-sparing, early transfusion approach for resuscitation of injured children.
LEVEL OF EVIDENCE
Therapeutic, level IV.
背景
本研究旨在确定在输注血液制品之前晶体液的时间和量与死亡率之间的关系，假设更早的输血和更少的晶体液输注与改善结果相关。
方法
这是一项多机构前瞻性观察性研究，纳入了 2018 年 4 月至 2019 年 9 月期间因年龄调整后的休克指数升高而从受伤现场转运的 18 岁以下儿科创伤患者。评估了院前、急诊科和初始入院复苏的容量和时间，包括总体和输血前计算 20±10mL/kg 的晶体液冲击量。多变量 Cox 比例风险和逻辑回归模型确定了与死亡率和延长重症监护、呼吸机和住院天数相关的因素。
结果
在 24 个创伤中心的 712 名儿童中，平均年龄为 7.6 岁，中位数（四分位间距）损伤严重度评分 9（2-20），院内死亡率为 5.3%（n=38）。有 311 名患者（43.7%）接受了至少一次晶体液冲击量，149 名患者（20.9%）接受了血液制品，其中 65 名患者（9.6%）接受了大量输血激活。一半（53.3%）接受了多次晶体液冲击量的患者需要输血。先接受血液制品的患者（n=41）的输血中位时间更短（19.8 分钟 vs. 78.0 分钟，p=0.005），总液体量更少（50.4 毫升/kg vs. 86.6 毫升/kg，p=0.033），尽管损伤严重度评分相似（中位数 22 分 vs. 27 分，p=0.40）。多变量分析显示，死亡率无相关性（p=0.51）；然而，在首次冲击量之后的每次晶体液冲击量与机械通气时间延长、重症监护病房和住院天数延长的几率增加相关（均 p<0.05）。输血时间延长与机械通气时间延长相关（比值比，1.11；p=0.04）。
结论
在这项前瞻性研究中，多次晶体液冲击量复苏与输血需求增加和预后恶化相关，包括机械通气时间和住院时间延长。这些数据支持对受伤儿童进行晶体液节约、早期输血的复苏方法。
证据水平
治疗性，IV 级。
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