死亡率高峰：确定持续大量输血中的平台期。

Cresting mortality: Defining a plateau in ongoing massive transfusion.

机构信息

From the Center for Trauma and Critical Care, Department of Surgery (M.T.Q., J.A.Z., P.C., J.E., B.S., C.C.), Department of Anesthesia (A.V., M.C.), George Washington University, Washington, District of Columbia; Division of Trauma and Emergency Surgery, Department of Surgery (M.P.F., S.M.), School of Medical Sciences (M.P.F., S.M.), and Clinical Epidemiology and Biostatistics (Y.C.), School of Medical Sciences, Orebro University, Orebro, Sweden.

出版信息

J Trauma Acute Care Surg. 2022 Jul 1;93(1):43-51. doi: 10.1097/TA.0000000000003641. Epub 2022 Apr 8.

DOI:10.1097/TA.0000000000003641

PMID:35393379

Abstract

BACKGROUND

Blood-based balanced resuscitation is a standard of care in massively bleeding trauma patients. No data exist as to when this therapy no longer significantly affects mortality. We sought to determine if there is a threshold beyond which further massive transfusion will not affect in-hospital mortality.

METHODS

The Trauma Quality Improvement database was queried for all adult patients registered between 2013 and 2017 who received at least one unit of blood (packed red blood cell) within 4 hours of arrival. In-hospital mortality was evaluated based on the total transfusion volume (TTV) at 4 hours and 24 hours in the overall cohort (OC) and in a balanced transfusion cohort, composed of patients who received transfusion at a ratio of 1:1 to 2:1 packed red blood cell to plasma. A bootstrapping method in combination with multivariable Poisson regression was used to find a cutoff after which additional transfusion no longer affected in-hospital mortality. Multivariable Poisson regression was used to control for age, sex, race, highest Abbreviated Injury Scale score in each body region, comorbidities, advanced directives limiting care, and the primary surgery performed for hemorrhage control.

RESULTS

The OC consisted of 99,042 patients, of which 28,891 and 30,768 received a balanced transfusion during the first 4 hours and 24 hours, respectively. The mortality rate plateaued after a TTV of 40.5 units (95% confidence interval [CI], 40-41) in the OC at 4 hours and after a TTV of 52.8 units (95% CI, 52-53) at 24 hours following admission. In the balanced transfusion cohort, mortality plateaued at a TTV of 39 units (95% CI, 39-39) and 53 units (95% CI, 53-53) at 4 hours and 24 hours following admission, respectively.

CONCLUSION

Transfusion thresholds exist beyond which ongoing transfusion is not associated with any clinically significant change in mortality. These TTVs can be used as markers for resuscitation timeouts to assess the plan of care moving forward.

LEVEL OF EVIDENCE

Prognostic and epidemiological, Level III.

摘要

背景

在大量出血性创伤患者中，基于血液的平衡复苏是一种标准的治疗方法。目前还没有数据表明何时这种治疗方法不再显著影响死亡率。我们试图确定是否存在一个阈值，超过这个阈值，进一步的大量输血将不会影响住院死亡率。

方法

从 2013 年至 2017 年期间接受至少一个单位血液（浓缩红细胞）在到达后 4 小时内登记的所有成年患者的创伤质量改进数据库中查询。根据总输血量（TTV）评估住院死亡率 4 小时和 24 小时，在总体队列（OC）和平衡输血队列中，接受输血比例为 1:1 至 2:1 浓缩红细胞与血浆。采用bootstrap 方法结合多变量泊松回归确定一个截止值，超过该值，额外输血不再影响住院死亡率。多变量泊松回归用于控制年龄、性别、种族、每个身体区域的最高损伤严重程度评分、合并症、限制护理的高级指令以及为控制出血而进行的主要手术。

结果

OC 包括 99042 名患者，其中 28891 名和 30768 名分别在入院后前 4 小时和 24 小时接受了平衡输血。OC 在入院后 4 小时 TTV 为 40.5 单位（95%置信区间[CI]，40-41）和 24 小时 TTV 为 52.8 单位（95%CI，52-53）时，死亡率达到平台期。在平衡输血队列中，入院后 4 小时和 24 小时的 TTV 分别达到 39 单位（95%CI，39-39）和 53 单位（95%CI，53-53）时，死亡率达到平台期。