From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland.
J Trauma Acute Care Surg. 2021 Nov 1;91(5):841-848. doi: 10.1097/TA.0000000000003245.
Damage-control resuscitation (DCR) improves survival in severely bleeding patients. However, deviating from balanced transfusion ratios during a resuscitation may limit this benefit. We hypothesized that maintaining a balanced resuscitation during DCR is independently associated with improved survival.
This was a secondary analysis of the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. Patients receiving >3 U of packed red blood cells (PRBCs) during any 1-hour period over the first 6 hours and surviving beyond 30 minutes were included. Linear regression assessed the effect of percent time in a high-ratio range on 24-hour survival. We identified an optimal ratio and percent of time above the target ratio threshold by Youden's index. We compared patients with a 6-hour ratio above the target and above the percent time threshold (on-target) with all others (off-target). Kaplan-Meier analysis assessed the combined effect of blood product ratio and percent time over the target ratio on 24-hour and 30-day survival. Multivariable logistic regression identified factors independently associated with 24-hour and 30-day survival.
Of 1,245 PROMMTT patients, 524 met the inclusion criteria. Optimal targets were plasma/PRBC and platelet/PRBC of 0.75 (3:4) and ≥40% time spent over this threshold. For plasma/PRBC, on-target (n = 213) versus off-target (n = 311) patients were younger (median, 31 years; interquartile range, [22-50] vs. 40 [25-54]; p = 0.002) with similar injury burdens and presenting physiology. Similar patterns were observed for platelet/PRBC on-target (n = 116) and off-target (n = 408) patients. After adjusting for differences, on-target plasma/PRBC patients had significantly improved 24-hour (odds ratio, 2.25; 95% confidence interval, 1.20-4.23) and 30-day (odds ratio, 1.97; 95% confidence interval, 1.14-3.41) survival, while on-target platelet/PRBC patients did not.
Maintaining a high ratio of plasma/PRBC during DCR is independently associated with improved survival. Performance improvement efforts and prospective studies should capture time spent in a high-ratio range.
Epidemiologic/prognostic study, level II; Therapeutic, level IV.
控制性复苏（DCR）可提高严重出血患者的生存率。然而，在复苏过程中偏离平衡输血比例可能会限制这种益处。我们假设在 DCR 期间维持平衡复苏与生存率的提高有关。
这是 Prospective Observational Multicenter Major Trauma Transfusion（PROMMTT）研究的二次分析。纳入在最初 6 小时内任何 1 小时内接受 >3 U 浓缩红细胞（PRBC）且存活超过 30 分钟的患者。线性回归评估高比例范围内的时间百分比对 24 小时生存率的影响。我们通过 Youden 指数确定了最佳比例和高于目标比例阈值的时间百分比。我们将 6 小时内比例高于目标值且高于时间百分比阈值（目标内）的患者与所有其他患者（目标外）进行比较。Kaplan-Meier 分析评估了血液制品比例和高于目标比例的时间对 24 小时和 30 天生存率的综合影响。多变量逻辑回归确定了与 24 小时和 30 天生存率独立相关的因素。
在 1245 名 PROMMTT 患者中，有 524 名符合纳入标准。最佳目标是血浆/PRBC 和血小板/PRBC 的比例为 0.75（3:4），并且有≥40%的时间超过该阈值。对于血浆/PRBC，目标内（n = 213）与目标外（n = 311）患者的年龄较小（中位数 31 岁；四分位距[22-50] vs. 40 [25-54]；p = 0.002），受伤程度和入院生理情况相似。血小板/PRBC 目标内（n = 116）和目标外（n = 408）患者也观察到类似的模式。在调整差异后，目标内血浆/PRBC 患者的 24 小时（比值比，2.25；95%置信区间，1.20-4.23）和 30 天（比值比，1.97；95%置信区间，1.14-3.41）生存率显著提高，而目标内血小板/PRBC 患者则没有。
在 DCR 期间维持高血浆/PRBC 比例与生存率的提高有关。绩效改进工作和前瞻性研究应捕获高比例范围内的时间。
观察性/预后研究，Ⅱ级；治疗性，Ⅳ级。
