现代超大容量输血后的结局：东部创伤外科学会多中心研究。
Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study.
机构信息
From the Department of Surgery at Zuckerberg San Francisco General Hospital, University of California San Francisco (Z.A.M., Z.J.H., R.A.C., B.N.-G., L.Z.K., E.E.R., J.J.P., B.R., M.K.A., A.T.F.), San Francisco, California; Department of Epidemiology and Biostatistics, University of California San Francisco (E.C.M), San Francisco, California; Department of Laboratory Medicine, University of California, San Francisco (J.H.E., A.N., J.M.), San Francisco, California; Department of Surgery, University of California Irvine (W.D., J.N.), Irvine, Orange, California; Department of Surgery, Ohio Health Grant Medical Center (A.K.L., M.C.S.), Columbus, Ohio; Department of Surgery, University of Kentucky (S.S.D., J.K.R.), Lexington, Kentucky; Department of Surgery, Miami Valley Hospital (H.L., Y.W., C.H.), Dayton, Ohio; Department of Surgery, R Adams Cowley Shock Trauma Center (A.M.C., R.A.K., P.T.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery, Loma Linda Medical Center (L.P., K.M., X.L.-O.), Loma Linda, California; Department of Surgery, University of Kansas Medical Center (K.T., C.A.G.), Kansas City, Kansas; Department of Surgery, Crozer-Chester Medical Center (S.S.S., A.R.), Upland, Pennsylvania; Department of Surgery, WakeMed Health and Hospitals (A.M., P.U., A.S., B.P., K.T.), Raleigh, North Carolina; Department of Surgery, University of New Mexico School of Medicine (K.M., S.A.M.), Albuquerque, New Mexico; Department of Surgery, Wellspan York Hospital (J.G.), York, Pennsylvania; Department of Surgery, Ascension Via Christi Hospitals St. Francis (J.K., J.H., K.L.), Wichita, Kansas; Department of Surgery, Maine Medical Center (J.B.O., D.C.C.), Portland, Maine; Department of Surgery, South Shore Hospital/Brigham and Women's Hospital (S.A.S., J.C.K.), Boston, Massachusetts; Department of Surgery, Penn State Hershey Medical Center (J.G., J.P.H.), Hershey, Pennsylvania; Department of Surgery, Northwestern University Feinberg School of Medicine (A.Z.B., J.A.P.), Chicago, Illinois; Department of Surgery, University of California (R.A.C.), UC Davis, Sacramento, California; Department of Surgery, Ryder Trauma Center (K.A.J., G.R.), University of Miami Miller School of Medicine, Miami, Florida; and Washington University School of Medicine St. Louis (J.K.), Missouri.
出版信息
J Trauma Acute Care Surg. 2021 Jul 1;91(1):24-33. doi: 10.1097/TA.0000000000003121.
BACKGROUND
Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era.
METHODS
An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality.
RESULTS
The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%).
CONCLUSION
Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication.
LEVEL OF EVIDENCE
Prognostic, level III.
背景
尽管现代大量输血方案广泛采用平衡的血液制品比例，但在 24 小时内接受超大剂量输血（定义为≥20U 红细胞[RBC]）的创伤患者的存活率仍然较低，资源消耗仍然较高。因此，我们旨在确定在现代复苏时代接受超大剂量输血的创伤患者死亡的相关因素。
方法
对来自 17 个创伤中心的 461 例创伤患者进行了东部创伤外科学会多中心回顾性研究，这些患者在 24 小时内接受了≥20U 的 RBC（2014-2019 年）。使用多变量逻辑回归和分类回归树分析来确定与死亡率相关的临床特征。
结果
461 例患者年龄较小（中位数年龄 35 岁），男性（82%），严重受伤（中位数损伤严重程度评分 33 分），休克（中位数休克指数 1.2；基础不足，-9），并输注了中位数 29U 的 RBC、22U 的新鲜冷冻血浆（FFP）和 24U 的血小板（PLT）。24 小时死亡率为 46%，出院时死亡率为 65%。输注 RBC/FFP≥1.5:1 或 RBC/PLT≥1.5:1 与死亡率显著相关，对于接受 RBC/PLT 和 RBC/FFP≥1.5:1 的 18%的患者最为明显（24 小时和出院时的死亡率比，分别为 3.11 和 2.81；两者均 p<0.01）。分类回归树确定年龄大于 50 岁、初始格拉斯哥昏迷评分低、血小板减少症和抢救性开胸术与生存几率低（14-26%）相关，而没有这些因素与生存几率高（71%）相关。
结论
尽管采用了现代大量输血方案，但在接受超大剂量输血的创伤患者中，有一半以上的患者输注 RBC/FFP 或 RBC/PLT 的比例不平衡≥1.5:1，死亡率增加。在超大剂量输血期间保持对平衡比例的关注至关重要，考虑到年龄较大、初始精神状态不佳、血小板减少症和抢救性开胸术可以帮助预测预后。
证据水平
预后，III 级。
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