From the Division of General Surgery, Department of Surgery (T.L.), The Ottawa Hospital; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Division of Critical Care, Department of Medicine (A.T.), The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Regional Trauma Program and Division of General Surgery, Department of Surgery (J.L.), The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute (J.L.), Ottawa, Ontario, Canada; Library and Information Sciences (R.S.), The Ottawa Hospital Ottawa, Ontario, Canada; Clinical Epidemiology Program (M.T.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; and Department of Emergency Medicine (C.V.), The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute (C.V.); and School of Epidemiology and Public Health (C.V.), University of Ottawa, Ottawa, Ontario, Canada.
J Trauma Acute Care Surg. 2023 Aug 1;95(2):267-275. doi: 10.1097/TA.0000000000003976. Epub 2023 Mar 28.
Uncontrolled bleeding is a common cause of preventable mortality in trauma. While it is intuitive that delays to hemostasis may lead to worse outcomes, the impacts of these delays remain incompletely explored. This systematic review aimed to characterize the extant definitions of delayed hemostatic intervention and to quantify the impacts of delays on clinical outcomes.
We searched EMBASE, MEDLINE, and Web of Science from inception to August 2022. Studies defining "delayed intervention" and those comparing times to intervention among adults presenting to hospital with blunt or penetrating injuries who required major hemostatic intervention were eligible. The coprimary outcomes were mortality and the definition of delay to hemostasis used. Secondary outcomes included units of packed red blood cells received, length of stay in hospital, and length of stay in intensive care.
We identified 2,050 studies, with 24 studies including 10,168 patients meeting the inclusion criteria. The majority of studies were retrospective observational cohort studies, and most were at high risk of bias. A variety of injury patterns and hemostatic interventions were considered, with 69.6% of studies reporting a statistically significant impact of increased time to intervention on mortality. Definitions of delayed intervention ranged from 10 minutes to 4 hours. Conflicting data were reported for impact of time on receipt of blood products, while one study found a significant impact on intensive care length of stay. No studies assessed length of stay in hospital.
The extant literature is heterogeneous with respect to injuries included, methods of hemostasis employed, and durations of delay examined. While the majority of the included studies demonstrated a statistically significant relationship between time to intervention and mortality, an evidence-informed definition of delayed intervention for bleeding trauma patients at large has not been solidified. In addition, standardized research is needed to establish targets, which could reduce morbidity and mortality.
Systematic Review; Level IV.
出血失控是创伤患者可预防死亡的常见原因。虽然止血延迟可能导致更糟糕的结果是直观的，但这些延迟的影响仍未得到充分探索。本系统评价旨在描述现有的止血干预延迟定义，并量化延迟对临床结果的影响。
我们从创建到 2022 年 8 月在 EMBASE、MEDLINE 和 Web of Science 中进行了搜索。符合纳入标准的研究定义了“延迟干预”，并比较了因钝器或穿透伤而到医院就诊、需要主要止血干预的成人到达医院至干预的时间。主要结局是死亡率和使用的止血延迟定义。次要结局包括接受的单位红细胞悬液、住院时间和重症监护病房停留时间。
我们确定了 2050 项研究，其中 24 项研究包括符合纳入标准的 10168 例患者。大多数研究是回顾性观察队列研究，且大多数研究存在较高的偏倚风险。考虑了各种损伤模式和止血干预措施，其中 69.6%的研究报告说，干预时间的增加对死亡率有统计学意义的影响。干预延迟的定义范围从 10 分钟到 4 小时不等。关于时间对血液制品输注的影响报告了相互矛盾的数据，而一项研究发现对重症监护病房停留时间有显著影响。没有研究评估住院时间。
现有文献在纳入的损伤、使用的止血方法和检查的延迟持续时间方面存在异质性。虽然大多数纳入的研究显示干预时间与死亡率之间存在统计学显著关系，但尚未确定针对广泛出血性创伤患者的延迟干预的循证定义。此外，需要进行标准化研究以确定目标，这可能会降低发病率和死亡率。
系统评价；IV 级。
