Kudo Daisuke, Yoshida Yoshitaro, Kushimoto Shigeki
Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
Department of Emergency and Critical Care Medicine, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
J Intensive Care. 2017 Jan 20;5(1):11. doi: 10.1186/s40560-016-0202-z.
Achieving a balance between organ perfusion and hemostasis is critical for optimal fluid resuscitation in patients with severe trauma. The concept of "permissive hypotension" refers to managing trauma patients by restricting the amount of resuscitation fluid and maintaining blood pressure in the lower than normal range if there is continuing bleeding during the acute period of injury. This treatment approach may avoid the adverse effects of early, high-dose fluid resuscitation, such as dilutional coagulopathy and acceleration of hemorrhage, but does carry the potential risk of tissue hypoperfusion. Current clinical guidelines recommend the use of permissive hypotension and controlled resuscitation. However, it is not mentioned which subjects would receive most benefit from this approach, when considering factors such as age, injury mechanism, setting, or the presence or absence of hypotension. Recently, two randomized clinical trials examined the efficacy of titrating blood pressure in younger patients with shock secondary to either penetrating or blunt injury; in both trials, overall mortality was not improved. Another two major clinical trials suggest that controlled resuscitation may be safe in patients with blunt injury in the pre-hospital setting and possibly lead to improved outcomes, especially in patients with pre-hospital hypotension. Some animal studies suggest that hypotensive resuscitation may improve outcomes in subjects with penetrating injury where bleeding occurs from only one site. On the other hand, hypotensive resuscitation in blunt trauma may worsen outcomes due to tissue hypoperfusion. The influence of these approaches on coagulation has not been sufficiently examined, even in animal studies. The effectiveness of permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation is still inconclusive, even when examining systematic reviews and meta-analyses. Further investigation is needed to elucidate the effectiveness of these approaches, so as to develop improved treatment strategies which take into account coagulopathy in the pathophysiology of trauma.
在严重创伤患者中实现器官灌注与止血之间的平衡对于优化液体复苏至关重要。“允许性低血压”的概念是指在创伤患者受伤急性期持续出血时，通过限制复苏液量并将血压维持在低于正常范围来进行管理。这种治疗方法可能避免早期大剂量液体复苏的不良反应，如稀释性凝血病和出血加速，但确实存在组织灌注不足的潜在风险。当前临床指南推荐使用允许性低血压和控制性复苏。然而，在考虑年龄、损伤机制、环境或是否存在低血压等因素时，并未提及哪些受试者将从这种方法中获益最多。最近，两项随机临床试验研究了对因穿透性或钝性损伤继发休克的年轻患者进行血压滴定的疗效；在这两项试验中，总体死亡率均未改善。另外两项主要临床试验表明，在院前环境中，控制性复苏对钝性损伤患者可能是安全的，并且可能改善预后，尤其是对院前低血压患者。一些动物研究表明，低血压复苏可能改善仅从一个部位出血的穿透性损伤受试者的预后。另一方面，钝性创伤中的低血压复苏可能因组织灌注不足而使预后恶化。即使在动物研究中，这些方法对凝血的影响也未得到充分研究。即使在审查系统评价和荟萃分析时，允许性低血压/低血压复苏以及限制性/控制性复苏的有效性仍不明确。需要进一步研究以阐明这些方法的有效性，从而制定出在创伤病理生理学中考虑凝血病的改进治疗策略。
