院前协同作用：氨甲环酸与输血在出血风险患者中的应用。
Prehospital synergy: Tranexamic acid and blood transfusion in patients at risk for hemorrhage.
机构信息
From the Division of Trauma and General Surgery, Department of Surgery (A.-P.D., L.H., S.L., M.D.N., J.L.S., J.B.B.), Department of Emergency Medicine (F.X.G.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (B.J.E.), University of Texas Health San Antonio, San Antonio, Texas; Department of Surgery (R.N.), University of Utah, Salt Lake City, Utah; and Department of Surgery (G.A.V., T.O.K., B.J.), University of Arizona, Tucson, Arizona.
出版信息
J Trauma Acute Care Surg. 2022 Jul 1;93(1):52-58. doi: 10.1097/TA.0000000000003620. Epub 2022 Apr 8.
BACKGROUND
Growing evidence supports improved survival with prehospital blood products. Recent trials show a benefit of prehospital tranexamic acid (TXA) administration in select subgroups. Our objective was to determine if receiving prehospital packed red blood cells (pRBC) in addition to TXA improved survival in injured patients at risk of hemorrhage.
METHODS
We performed a secondary analysis of all scene patients from the Study of Tranexamic Acid during Air and ground Medical Prehospital transport trial. Patients were randomized to prehospital TXA or placebo. Some participating EMS services utilized pRBC. Four resuscitation groups resulted: TXA, pRBC, pRBC+TXA, and neither. Our primary outcome was 30-day mortality and secondary outcome was 24-hour mortality. Cox regression tested the association between resuscitation group and mortality while adjusting for confounders.
RESULTS
A total of 763 patients were included. Patients receiving prehospital blood had higher Injury Severity Scores in the pRBC (22 [10, 34]) and pRBC+TXA (22 [17, 36]) groups than the TXA (12 [5, 21]) and neither (10 [4, 20]) groups (p < 0.01). Mortality at 30 days was greatest in the pRBC+TXA and pRBC groups at 18.2% and 28.6% compared with the TXA only and neither groups at 6.6% and 7.4%, respectively. Resuscitation with pRBC+TXA was associated with a 35% reduction in relative hazards of 30-day mortality compared with neither (hazard ratio, 0.65; 95% confidence interval, 0.45-0.94; p = 0.02). No survival benefit was observed in 24-hour mortality for pRBC+TXA, but pRBC alone was associated with a 61% reduction in relative hazards of 24-hour mortality compared with neither (hazard ratio, 0.39; 95% confidence interval, 0.17-0.88; p = 0.02).
CONCLUSION
For injured patients at risk of hemorrhage, prehospital pRBC+TXA is associated with reduced 30-day mortality. Use of pRBC transfusion alone was associated with a reduction in early mortality. Potential synergy appeared only in longer-term mortality and further work to investigate mechanisms of this therapeutic benefit is needed to optimize the prehospital resuscitation of trauma patients.
LEVEL OF EVIDENCE
Therapeutic/Care Management; Level III.
背景
越来越多的证据表明，在院前使用血液制品可以提高生存率。最近的试验表明，在某些特定亚组中，院前使用氨甲环酸（TXA）有获益。我们的目的是确定在有出血风险的受伤患者中，除了 TXA 之外，院前输注红细胞悬液（pRBC）是否能提高生存率。
方法
我们对来自空中和地面医疗院前转运试验中的 Tranexamic Acid during Air and ground Medical Prehospital transport trial 研究中的所有现场患者进行了二次分析。患者被随机分配到院前 TXA 或安慰剂组。一些参与的 EMS 服务使用了 pRBC。结果有 4 个复苏组：TXA、pRBC、pRBC+TXA 和两者都不用。我们的主要结局是 30 天死亡率，次要结局是 24 小时死亡率。Cox 回归分析调整混杂因素后，评估复苏组与死亡率之间的关系。
结果
共纳入 763 例患者。接受院前输血的患者在 pRBC（22 [10, 34]）和 pRBC+TXA（22 [17, 36]）组的损伤严重程度评分（ISS）高于 TXA（12 [5, 21]）和两者都不用（10 [4, 20]）组（p < 0.01）。30 天死亡率最高的是 pRBC+TXA 和 pRBC 组，分别为 18.2%和 28.6%，而 TXA 组和两者都不用组分别为 6.6%和 7.4%。与两者都不用组相比，pRBC+TXA 组 30 天的相对危险度降低了 35%（风险比，0.65；95%置信区间，0.45-0.94；p = 0.02）。在 24 小时死亡率方面，pRBC+TXA 组无生存获益，但 pRBC 组与两者都不用组相比，24 小时死亡率的相对危险度降低了 61%（风险比，0.39；95%置信区间，0.17-0.88；p = 0.02）。
结论
对于有出血风险的受伤患者，院前输注 pRBC+TXA 可降低 30 天死亡率。单独使用 pRBC 输血与降低早期死亡率有关。这种治疗效益的协同作用似乎只出现在更长时间的死亡率上，需要进一步的研究来探讨这种治疗效益的机制，以优化创伤患者的院前复苏。
证据水平
治疗/护理管理；III 级。
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