From the Division of Trauma and General Surgery, Department of Surgery (Deeb, Lu, Peitzman, Sperry, Brown).
Department of Emergency Medicine (Guyette), University of Pittsburgh Medical Center, Pittsburgh, PA.
J Am Coll Surg. 2023 Aug 1;237(2):183-194. doi: 10.1097/XCS.0000000000000695. Epub 2023 Mar 28.
Prehospital resuscitation guidelines vary widely, and blood products, although likely superior, are not available for most patients in the prehospital setting. Our objective was to determine the prehospital crystalloid volume associated with the lowest mortality among patients in hemorrhagic shock.
This is a secondary analysis of the Prehospital Air Medical Plasma trial. Injured patients from the scene with hypotension and tachycardia or severe hypotension were included. Segmented regression and generalized additive models were used to evaluate nonlinear effects of prehospital crystalloid volume on 24-hour mortality. Logistic regression evaluated the association between risk-adjusted mortality and prehospital crystalloid volume ranges to identify optimal target volumes. Inverse propensity weighting was performed to account for patient heterogeneity.
There were 405 patients included. Segmented regression suggested the nadir of 24-hour mortality lay within 377 to 1,419 mL prehospital crystalloid. Generalized additive models suggested the nadir of 24-hour mortality lay within 242 to 1,333 mL prehospital crystalloid. A clinically operationalized range of 250 to 1,250 mL was selected based on these findings. Odds of 24-hour mortality were higher for patients receiving less than 250 mL (adjusted odds ratio [aOR] 2.46; 95% CI 1.31 to 4.83; p = 0.007) and greater than 1,250 mL (aOR 2.57; 95% CI 1.24 to 5.45; p = 0.012) compared with 250 to 1,250 mL. Propensity-weighted regression similarly demonstrated odds of 24-hour mortality were higher for patients receiving less than 250 mL (aOR 2.62; 95% CI 1.34 to 5.12; p = 0.005) and greater than 1,250 mL (aOR 2.93; 95% CI 1.36 to 6.29; p = 0.006) compared with 250 to 1,250 mL.
Prehospital crystalloid volumes between 250 and 1,250 mL are associated with lower mortality compared with lower or higher volumes. Further work to validate these finding may provide practical volume targets for prehospital crystalloid resuscitation.
院前复苏指南差异很大，虽然血液制品可能更优，但在院前环境中，大多数患者都无法获得。我们的目的是确定与失血性休克患者最低死亡率相关的院前晶体液量。
这是院前航空医疗血浆试验的二次分析。从现场低血压伴心动过速或严重低血压的受伤患者中纳入研究对象。使用分段回归和广义加性模型评估院前晶体液量对 24 小时死亡率的非线性影响。Logistic 回归评估风险调整后死亡率与院前晶体液量范围之间的关系，以确定最佳目标量。采用逆倾向评分法来解释患者的异质性。
共纳入 405 例患者。分段回归提示 24 小时死亡率的最低点位于院前晶体液 377 至 1419 毫升之间。广义加性模型提示 24 小时死亡率的最低点位于院前晶体液 242 至 1333 毫升之间。根据这些发现，选择了一个临床操作化的 250 至 1250 毫升的范围。与 250 至 1250 毫升相比，接受少于 250 毫升（校正比值比[aOR]2.46；95%CI1.31 至 4.83；p=0.007）和大于 1250 毫升（aOR2.57；95%CI1.24 至 5.45；p=0.012）的患者 24 小时死亡率的可能性更高。倾向评分加权回归同样表明，与 250 至 1250 毫升相比，接受少于 250 毫升（aOR2.62；95%CI1.34 至 5.12；p=0.005）和大于 1250 毫升（aOR2.93；95%CI1.36 至 6.29；p=0.006）的患者 24 小时死亡率的可能性更高。
与较低或较高容量相比，250 至 1250 毫升之间的院前晶体液量与死亡率降低相关。进一步验证这些发现的工作可能为院前晶体复苏提供实用的容量目标。
