血栓弹力描记术指导下严重创伤患者的止血复苏：一项倾向评分匹配研究。

Thromboelastometry-guided haemostatic resuscitation in severely injured patients: a propensity score-matched study.

机构信息

Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Pierre Bénite Cedex, France.

Research on Healthcare Performance (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, Lyon, France.

出版信息

Crit Care. 2023 Apr 13;27(1):141. doi: 10.1186/s13054-023-04421-w.

DOI:10.1186/s13054-023-04421-w

PMID:37055832

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10103518/

Abstract

BACKGROUND

To accelerate the diagnosis and treatment of trauma-induced coagulopathy (TIC), viscoelastic haemostatic assays (VHA) are increasingly used worldwide, although their value is still debated, with a recent randomised trial showing no improvement in outcome. The objective of this retrospective study was to compare 2 cohorts of injured patients in which TIC was managed with either a VHA-based algorithm or a conventional coagulation test (CCT)-based algorithm.

METHODS

Data were retrieved from 2 registries and patients were included in the study if they received at least 1 unit of red blood cell in the first 24 h after admission. A propensity score, including sex, age, blunt vs. penetrating, systolic blood pressure, GCS, ISS and head AIS, admission lactate and PT, tranexamic acid administration, was then constructed. Primary outcome was the proportion of subjects who were alive and free of massive transfusion (MT) at 24 h after injury. We also compared the cost for blood products and coagulation factors.

RESULTS

From 2012 to 2019, 7250 patients were admitted in the 2 trauma centres, and among these 624 were included in the study (CCT group: 380; VHA group: 244). After propensity score matching, 215 patients remained in each study group without any significant difference in demographics, vital signs, injury severity, or laboratory analysis. At 24 h, more patients were alive and free of MT in the VHA group (162 patients, 75%) as compared to the CCT group (112 patients, 52%; p < 0.01) and fewer patients received MT (32 patients, 15% vs. 91 patients, 42%, p < 0.01). However, no significant difference was observed for mortality at 24 h (odds ratio 0.94, 95% CI 0.59-1.51) or survival at day 28 (odds ratio 0.87, 95% CI 0.58-1.29). Overall cost of blood products and coagulation factors was dramatically reduced in the VHA group as compared to the CCT group (median [interquartile range]: 2357 euros [1108-5020] vs. 4092 euros [2510-5916], p < 0.001).

CONCLUSIONS

A VHA-based strategy was associated with an increase of the number of patients alive and free of MT at 24 h together with an important reduction of blood product use and associated costs. However, that did not translate into an improvement in mortality.

摘要

背景

为了加速创伤性凝血病（TIC）的诊断和治疗，粘弹性止血检测（VHA）在全球范围内得到了越来越多的应用，尽管其价值仍存在争议，最近的一项随机试验显示治疗结果没有改善。本回顾性研究的目的是比较两组接受 VHA 或传统凝血试验（CCT）为基础的算法管理的创伤患者。

方法

从两个登记处检索数据，纳入至少在入院后 24 小时内输注 1 个单位红细胞的患者。然后构建包括性别、年龄、钝性与穿透性、收缩压、GCS、ISS 和头部 AIS、入院时的乳酸和 PT、氨甲环酸的使用情况的倾向评分。主要结局是在受伤后 24 小时存活且无大量输血（MT）的患者比例。我们还比较了血液制品和凝血因子的成本。

结果

2012 年至 2019 年，两个创伤中心共收治了 7250 名患者，其中 624 名患者纳入研究（CCT 组：380 名；VHA 组：244 名）。在进行倾向评分匹配后，每组各有 215 名患者，两组在人口统计学、生命体征、损伤严重程度或实验室分析方面无明显差异。在 24 小时时，VHA 组有更多的患者存活且无 MT（162 名，75%），而 CCT 组（112 名，52%；p<0.01），且 VHA 组 MT 输注较少（32 名，15% vs. 91 名，42%，p<0.01）。然而，24 小时死亡率无显著差异（比值比 0.94，95%可信区间 0.59-1.51）或 28 天存活率（比值比 0.87，95%可信区间 0.58-1.29）。与 CCT 组相比，VHA 组的血液制品和凝血因子总费用显著降低（中位数[四分位数范围]：2357 欧元[1108-5020] vs. 4092 欧元[2510-5916]，p<0.001）。