输血量与存活率的关系：何时才是极限？

When is enough enough? Odds of survival by unit transfused.

机构信息

From the Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.

出版信息

J Trauma Acute Care Surg. 2023 Feb 1;94(2):205-211. doi: 10.1097/TA.0000000000003835. Epub 2022 Nov 10.

DOI:10.1097/TA.0000000000003835

PMID:36694331

Abstract

BACKGROUND

Balanced transfusion is lifesaving for hemorrhagic shock. The American Red Cross critical blood shortage in 2022 threatened the immediate availability of blood. To eliminate waste, we reviewed the utility of transfusions per unit to define expected mortality at various levels of balanced transfusion.

METHODS

A retrospective study of 296 patients receiving massive transfusion on presentation at a level 1 trauma center was performed from January 2018 to December 2021. Units of packed red blood cells (PRBCs), fresh frozen plasma (FFP), and platelets received in the first 4 hours were recorded. Patients were excluded if they died in the emergency department, died on arrival, received <2 U PRBCs or FFP, or received PRBC/FFP >2:1. Primary outcomes were mortality and odds of survival to discharge. Subgroups were defined as transfused if receiving 2 to 9 U PRBCs, massive transfusion for 10 to 19 U PRBCs, and ultramassive transfusion for ≥20 U PRBCs.

RESULTS

A total of 207 patients were included (median age, 32 years; median Injury Severity Score, 25; 67% with penetrating mechanism). Mortality was 29% (61 of 207 patients). Odds of survival is equal to odds of mortality at 11 U PRBCs (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.50-1.79). Beyond 16 U PRBCs, odds of mortality exceed survival (OR, 0.36; 95% CI, 0.16-0.82). Survival approaches zero >36 U PRBCs (OR, 0.09; 95% CI, 0.00-0.56). Subgroup mortality rates increased with unit transfused (16% transfused vs. 36% massive transfusion, p = 0.003; 36% massive transfusion vs. 67% ultramassive transfusion, p = 0.006).

CONCLUSION

Mortality increases with each unit balanced transfusion. Surgeons should view efforts heroic beyond 16 U PRBCs/4 hours and near futile beyond 36 U PRBCs/4 hours. While extreme outliers can survive, consider cessation of resuscitation beyond 36 U PRBCs. This is especially true if hemostasis has not been achieved or blood supplies are limited.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.

摘要

背景

平衡输血对失血性休克患者具有救命作用。2022 年美国红十字会出现严重的血液短缺，危及血液的即时供应。为了避免浪费，我们评估了单位输血的效果，以确定在不同的平衡输血水平下的预期死亡率。

方法

对 2018 年 1 月至 2021 年 12 月期间在 1 级创伤中心就诊时接受大量输血的 296 名患者进行了回顾性研究。记录了在最初 4 小时内接受的红细胞（PRBC）、新鲜冷冻血浆（FFP）和血小板的单位数。如果患者在急诊科死亡、到达时死亡、接受 <2U PRBC 或 FFP 或接受 PRBC/FFP >2:1，则将其排除在外。主要结局是死亡率和出院时存活的几率。亚组定义为接受 2 至 9U PRBC、接受 10 至 19U PRBC 的大量输血和接受≥20U PRBC 的超大剂量输血。

结果

共有 207 名患者纳入研究（中位年龄 32 岁；中位损伤严重程度评分 25；67%为穿透性损伤机制）。死亡率为 29%（207 名患者中有 61 名）。存活的几率与第 11U PRBC 时的死亡率相同（比值比 [OR]，0.95；95%置信区间 [CI]，0.50-1.79）。超过 16U PRBC 后，死亡率超过存活率（OR，0.36；95%CI，0.16-0.82）。超过 36U PRBC 后，存活率接近零（OR，0.09；95%CI，0.00-0.56）。随着输注单位的增加，亚组死亡率也随之增加（输注 16% vs. 36%大量输血，p=0.003；36%大量输血 vs. 67%超大剂量输血，p=0.006）。