美国教学医院中接受大量输血的重伤患者生存率提高：一项全国性分析。

Improved survival for severely injured patients receiving massive transfusion at US teaching hospitals: A nationwide analysis.

作者信息

Ramsey Walter A, O'Neil Christopher F, Fils Aaron J, Botero-Fonnegra Cristina, Saberi Rebecca A, Gilna Gareth P, Pizano Louis R, Parker Brandon M, Proctor Kenneth G, Schulman Carl I, Namias Nicholas, Meizoso Jonathan P

机构信息

From the DeWitt Daughtry Family Department of Surgery (W.A.R., C.F.O., A.J.F., C.B.-F., R.A.S., G.P.G., L.R.P., B.M.P., K.G.P., C.I.S., N.N., J.P.M.), University of Miami Miller School of Medicine; Ryder Trauma Center (W.A.R., C.F.O., C.B.-F., R.A.S., G.P.G., L.R.P., B.M.P., K.G.P., C.I.S., N.N., J.P.M.), Jackson Memorial Hospital, Miami, Florida.

出版信息

J Trauma Acute Care Surg. 2023 May 1;94(5):672-677. doi: 10.1097/TA.0000000000003895. Epub 2023 Feb 6.

DOI:10.1097/TA.0000000000003895

PMID:36749659

Abstract

BACKGROUND

Previous studies have shown improved survival for patients treated at American College of Surgeons (ACS)-verified level I trauma centers compared with level II, level III, and undesignated centers. This mortality difference is more pronounced in severely injured patients. However, a survival benefit for severely injured trauma patients has not been established at teaching institutions compared with nonteaching centers. Because massive transfusion (MT) is associated with high mortality, we hypothesize that patients receiving MT have lower mortality at teaching hospitals than at nonteaching hospitals.

METHODS

All adult ACS Trauma Quality Improvement Program-eligible patients who underwent MT, defined as >10 U of packed red blood cells in the first 4 hours after arrival, in the 2019 ACS Trauma Quality Programs participant use file were eligible. Patients with severe head injury (head Abbreviated Injury Scale score, ≥3), prehospital cardiac arrest, and interhospital transfers were excluded. Logistic regression models were used to assess the effects of trauma center hospital teaching status on the adjusted odds of 3-hour, 6-hour, and 24-hour mortality.

RESULTS

A total of 1,849 patients received MT (81% male; median Injury Severity Score, 26 [18-35]), 72% were admitted to level I trauma centers, and 28% were admitted to level II centers. Overall hospital mortality was 41%; 17% of patients died in 3 hours, 25% in 6 hours, and 33% in 24 hours. Teaching hospitals were associated with decreased 3-hour (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.27-0.75), 6-hour (OR, 0.37; 95% CI, 0.24-0.56), 24-hour (OR, 0.50; 95% CI, 0.34-0.75), and overall mortality (OR, 0.66; 95% CI, 0.44-0.98), compared with nonteaching hospitals, controlling for sex, age, heart rate, injury severity, injury mechanism, and trauma center verification level.

CONCLUSION

Severely injured patients requiring MT experience significantly lower mortality at teaching hospitals compared with nonteaching hospitals, independently of trauma center verification level.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

摘要

背景

先前的研究表明，与二级、三级及未指定级别的创伤中心相比，在美国外科医师学会（ACS）认证的一级创伤中心接受治疗的患者生存率更高。这种死亡率差异在重伤患者中更为明显。然而，与非教学医院相比，教学机构中重伤创伤患者的生存获益尚未得到证实。由于大量输血（MT）与高死亡率相关，我们假设接受MT的患者在教学医院的死亡率低于非教学医院。

方法

2019年ACS创伤质量项目参与者使用文件中所有符合ACS创伤质量改进项目条件的成年患者，若接受了MT（定义为到达后4小时内输注超过10单位浓缩红细胞）则符合入选标准。排除重度颅脑损伤（头部简明损伤量表评分≥3）、院前心脏骤停和院间转运的患者。使用逻辑回归模型评估创伤中心医院教学状况对3小时、6小时和24小时死亡率调整后比值比的影响。

结果

共有1849例患者接受了MT（81%为男性；损伤严重程度评分中位数为26[18 - 35]），72%的患者被收入一级创伤中心，28%的患者被收入二级创伤中心。总体医院死亡率为41%；17%的患者在3小时内死亡，25%在6小时内死亡，33%在24小时内死亡。与非教学医院相比，在控制性别、年龄、心率、损伤严重程度、损伤机制和创伤中心认证级别后，教学医院的3小时（比值比[OR]，0.45；95%置信区间[CI]，0.27 - 0.75）、6小时（OR，0.37；95% CI，0.24 - 0.56）、24小时（OR，0.50；95% CI，0.34 - 0.75）及总体死亡率（OR，0.66；95% CI，0.44 - 0.98）均降低。