From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington.
Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital-Harvard University, Boston, Massachusetts.
Anesth Analg. 2022 Aug 1;135(2):385-393. doi: 10.1213/ANE.0000000000005982. Epub 2022 May 6.
Incorporation of massive transfusion protocols (MTPs) into acute major trauma care has reduced hemorrhagic mortality, but the threshold and timing of platelet transfusion in MTP are controversial. This study aimed to describe early (first 4 hours) platelet transfusion practice in a setting where platelet counts are available within 15 minutes and the effect of early platelet deployment on in-hospital mortality. Our hypothesis in this work was that platelet transfusion in resuscitation of severe trauma can be guided by rapid turnaround platelet counts without excess mortality.
We examined MTP activations for all admissions from October 2016 to September 2018 to a Level 1 regional trauma center with a full trauma team activation. We characterized platelet transfusion practice by demographics, injury severity, and admission vital signs (as shock index: heart rate/systolic blood pressure) and laboratory results. A multivariable model assessed association between early platelet transfusion and mortality at 4 hours, 24 hours, and overall in-hospital, with P <.001.
Of the 11,474 new trauma patients admitted over the study period, 469 (4.0%) were massively transfused (defined as ≥10 units of red blood cells [RBCs] in 24 hours, ≥5 units of RBC in 6 hour, ≥3 units of RBC in 1 hour, or ≥4 units of total products in 30 minutes). 250 patients (53.0%) received platelets in the first 4 hours, and most early platelet transfusions occurred in the first hour after admission (175, 70.0%). Platelet recipients had higher injury severity scores (mean ± standard deviation [SD], 35 ± 16 vs 28 ± 14), lower admission platelet counts (189 ± 80 × 10 9 /L vs 234 ± 80 × 10 9 /L; P < .001), higher admission shock index (heart rate/systolic blood pressure; 1.15 ± 0.46 vs 0.98 ± 0.36; P < .001), and received more units of red cells in the first 4 hours (8.7 ± 7.7 vs 3.3 ± 1.6 units), 24 hours (9 ± 9 vs 3 ± 2 units), and in-hospital (9 ± 8 vs 3 ± 2 units) than nonrecipients (all P < .001). We saw no difference in 4-hour (8% vs 7.8%; P = .4), 24-hour (16.4% vs 10.5%; P = .06), or in-hospital mortality (30.4% vs 23.7%; P = .1) between platelet recipients and nonrecipients. After adjustment for age, injury severity, head injury, and admission physiology/laboratory results, early platelet transfusion was not associated with 4-hour, 24-hour, or in-hospital mortality.
In an advanced trauma care setting where platelet counts are available within 15 minutes, approximately half of massively transfused patients received early platelet transfusion. Early platelet transfusion guided by protocol-based clinical judgment and rapid-turnaround platelet counts was not associated with increased mortality.
将大量输血方案（MTP）纳入急性严重创伤护理可降低出血性死亡率，但 MTP 中血小板输注的阈值和时间仍存在争议。本研究旨在描述在血小板计数可在 15 分钟内获得的情况下，在设置中早期（前 4 小时）血小板输注的情况，并评估早期血小板的应用对院内死亡率的影响。我们的假设是，在严重创伤的复苏中，可以通过快速周转的血小板计数来指导血小板输注，而不会增加死亡率。
我们检查了 2016 年 10 月至 2018 年 9 月期间在具有完整创伤小组激活的 1 级区域创伤中心入院的所有 MTP 激活患者。我们通过人口统计学、损伤严重程度以及入院生命体征（休克指数：心率/收缩压）和实验室结果来描述血小板输注情况。多变量模型评估了早期血小板输注与 4 小时、24 小时和总体院内死亡率之间的相关性，P 值<.001。
在研究期间入院的 11474 例新创伤患者中，有 469 例（4.0%）大量输血（定义为 24 小时内输注≥10 单位红细胞[RBC]、6 小时内输注≥5 单位 RBC、1 小时内输注≥3 单位 RBC 或 30 分钟内输注≥4 个单位总产品）。250 例患者（53.0%）在入院的前 4 小时内输注血小板，大多数早期血小板输注发生在入院后的第一个小时内（175 例，70.0%）。血小板输注者的损伤严重程度评分较高（平均±标准差[SD]，35±16 比 28±14），入院时血小板计数较低（189±80×109/L 比 234±80×109/L；P<.001），入院时休克指数（心率/收缩压）较高（1.15±0.46 比 0.98±0.36；P<.001），前 4 小时（8.7±7.7 比 3.3±1.6 单位）、24 小时（9±9 比 3±2 单位）和院内（9±8 比 3±2 单位）输注的红细胞量也更多，而非输注者（均 P<.001）。我们发现，血小板输注者和非输注者在 4 小时（8%比 7.8%；P=.4）、24 小时（16.4%比 10.5%；P=.06）和院内死亡率（30.4%比 23.7%；P=.1）方面无差异。在校正年龄、损伤严重程度、头部损伤和入院生理/实验室结果后，早期血小板输注与 4 小时、24 小时或院内死亡率无关。
在血小板计数可在 15 分钟内获得的先进创伤护理环境中，大约一半的大量输血患者接受了早期血小板输注。根据基于方案的临床判断和快速周转的血小板计数指导的早期血小板输注与死亡率增加无关。
