From the School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus (H.B.M., E.E.M., M.J.C., M.P.C., A.S.), Aurora, CO; University of Colorado Anschutz Medical Campus, School of Public Health, Department of Health Systems, Management and Policy (A.S.); Aurora, Colorado; University of Pittsburgh (M.T.T., J.L.S., F.X.G., J.B.B., M.N., B.Z.), Pittsburgh, Pennsylvania; Ernest E. Moore Shock Trauma Center at Denver Health (E.E.M., M.J.C.), Denver, Colorado; and Combat Casualty Care Research Program (A.E.P.), US Army Medical Research Materiel Command, Fort Detrick, Maryland.
J Trauma Acute Care Surg. 2020 May;88(5):588-596. doi: 10.1097/TA.0000000000002614.
Randomized clinical trials (RCTs) support the use of prehospital plasma in traumatic hemorrhagic shock, especially in long transports. The citrate added to plasma binds with calcium, yet most prehospital trauma protocols have no guidelines for calcium replacement. We reviewed the experience of two recent prehospital plasma RCTs regarding admission ionized-calcium (i-Ca) blood levels and its impact on survival. We hypothesized that prehospital plasma is associated with hypocalcemia, which in turn is associated with lower survival.
We studied patients enrolled in two institutions participating in prehospital plasma RCTs (control, standard of care; experimental, plasma), with i-Ca collected before calcium supplementation. Adults with traumatic hemorrhagic shock (systolic blood pressure ≤70 mm Hg or 71-90 mm Hg + heart rate ≥108 bpm) were eligible. We use generalized linear mixed models with random intercepts and Cox proportional hazards models with robust standard errors to account for clustered data by institution. Hypocalcemia was defined as i-Ca of 1.0 mmol/L or less.
Of 160 subjects (76% men), 48% received prehospital plasma (median age, 40 years [interquartile range, 28-53 years]) and 71% suffered blunt trauma (median Injury Severity Score [ISS], 22 [interquartile range, 17-34]). Prehospital plasma and control patients were similar regarding age, sex, ISS, blunt mechanism, and brain injury. Prehospital plasma recipients had significantly higher rates of hypocalcemia compared with controls (53% vs. 36%; adjusted relative risk, 1.48; 95% confidence interval [CI], 1.03-2.12; p = 0.03). Severe hypocalcemia was significantly associated with decreased survival (adjusted hazard ratio, 1.07; 95% CI, 1.02-1.13; p = 0.01) and massive transfusion (adjusted relative risk, 2.70; 95% CI, 1.13-6.46; p = 0.03), after adjustment for confounders (randomization group, age, ISS, and shock index).
Prehospital plasma in civilian trauma is associated with hypocalcemia, which in turn predicts lower survival and massive transfusion. These data underscore the need for explicit calcium supplementation guidelines in prehospital hemotherapy.
Therapeutic, level II.
随机临床试验（RCT）支持在创伤性出血性休克中使用院前血浆，尤其是在长途转运中。添加到血浆中的柠檬酸盐与钙结合，但大多数院前创伤方案没有钙替代的指南。我们回顾了最近两项院前血浆 RCT 中关于入院离子钙（i-Ca）血水平及其对生存的影响的经验。我们假设院前血浆与低钙血症相关，而低钙血症又与较低的生存率相关。
我们研究了参加两项参与院前血浆 RCT 的机构（对照组，标准护理；实验组，血浆）中入组的患者，在补充钙之前采集 i-Ca。符合条件的是有创伤性出血性休克（收缩压≤70mmHg 或 71-90mmHg+心率≥108 次/分）的成年人。我们使用具有随机截距的广义线性混合模型和具有稳健标准误差的 Cox 比例风险模型，通过机构对聚类数据进行分析。低钙血症定义为 i-Ca 为 1.0mmol/L 或更低。
在 160 名患者（76%为男性）中，48%接受了院前血浆（中位年龄为 40 岁[四分位距，28-53 岁]），71%患有钝性创伤（中位损伤严重程度评分[ISS]，22[四分位距，17-34]）。与对照组相比，院前血浆组和对照组在年龄、性别、ISS、钝性机制和脑损伤方面无显著差异。与对照组相比，院前血浆组的低钙血症发生率明显更高（53%比 36%；调整后相对风险，1.48；95%置信区间[CI]，1.03-2.12；p=0.03）。严重低钙血症与生存率降低显著相关（调整后危险比，1.07；95%CI，1.02-1.13；p=0.01）和大出血（调整后相对风险，2.70；95%CI，1.13-6.46；p=0.03），调整混杂因素（随机分组、年龄、ISS 和休克指数）后。
在平民创伤中使用院前血浆与低钙血症相关，而低钙血症又与较低的生存率和大出血相关。这些数据强调了在院前血液治疗中需要明确的钙补充指南。
治疗，II 级。
