Muldowney Maeve, Liu Zhinan, Stansbury Lynn G, Vavilala Monica S, Hess John R
From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington.
Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington.
Anesth Analg. 2023 May 1;136(5):927-933. doi: 10.1213/ANE.0000000000006388. Epub 2023 Apr 14.
Uncontrolled bleeding is a leading cause of death in trauma. In the last 40 years, ultramassive transfusion (UMT; ≥20 units of red blood cells [RBCs]/24 hours) for trauma has been associated with 50% to 80% mortality; the question remains as to whether the increasing number of units transfused in urgent resuscitation is a marker of futility. We asked whether the frequency and outcomes of UMT have changed in the era of hemostatic resuscitation.
We performed a retrospective cohort study of all UMTs in the first 24 hours of care over an 11-year period at a major US level-1 adult and pediatric trauma center. UMT patients were identified, and a dataset was built by linking blood bank and trauma registry data, then reviewing individual electronic health records. Success in achieving hemostatic proportions of blood products was estimated as (units of plasma + apheresis-platelets-in-plasma + cryoprecipitate-pools + whole blood]/[all units given] ≥0.5. Demographics, injury type (blunt or penetrating), severity (Injury Severity Score [ISS]), severity pattern (Abbreviated Injury Scale score for head [AIS-Head] ≥4), admitting laboratory, transfusion, selected emergency department interventions, and discharge status were assessed using χ2 tests of categorical association, the Student t-test of means, and multivariable logistic regression. P <.05 was considered significant.
Among 66,734 trauma admissions from April 6, 2011 to December 31, 2021, we identified 6288 (9.4%) who received any blood products in the first 24 hours, 159 of whom received UMT (0.23%; 154 aged 18-90 + 5 aged 9-17), 81% in hemostatic proportions. Overall mortality was 65% (n = 103); mean ISS = 40; median time to death, 6.1 hours. In univariate analyses, death was not associated with age, sex, or more RBC units transfused beyond 20 but was associated with blunt injury, increasing injury severity, severe head injury, and failure to receive hemostatic blood product ratios. Mortality was also associated with decreased pH and evidence of coagulopathy at admission, especially hypofibrinogenemia. Multivariable logistic regression showed severe head injury, admission hypofibrinogenemia and not receiving a hemostatic resuscitation proportion of blood products as independently associated with death.
One in 420 acute trauma patients at our center received UMT, a historically low rate. A third of these patients lived, and UMT was not itself a marker of futility. Early identification of coagulopathy was possible, and failure to give blood components in hemostatic ratios was associated with excess mortality.
出血无法控制是创伤死亡的主要原因。在过去40年中，创伤患者接受超大量输血（UMT；≥20单位红细胞[RBCs]/24小时）后的死亡率为50%至80%；紧急复苏中输注单位数量的增加是否意味着徒劳仍存在疑问。我们探讨了在止血复苏时代UMT的频率和结果是否发生了变化。
我们对美国一家大型一级成人及儿科创伤中心11年间所有在护理的前24小时内接受UMT的患者进行了一项回顾性队列研究。确定UMT患者，并通过链接血库和创伤登记数据构建数据集，然后查阅个体电子健康记录。实现血液制品止血比例的成功定义为（血浆单位数+血浆中的单采血小板+冷沉淀池+全血）/（输注的所有单位数）≥0.5。使用分类关联的χ2检验、均值的学生t检验和多变量逻辑回归评估人口统计学、损伤类型（钝性或穿透性）、严重程度（损伤严重程度评分[ISS]）、严重程度模式（头部简明损伤量表评分[AIS-Head]≥4）、入院实验室检查、输血、选定的急诊科干预措施和出院状态。P<0.05被认为具有统计学意义。
在2011年4月6日至2021年12月31日期间的66734例创伤入院患者中，我们确定6288例（9.4%）在最初24小时内接受了任何血液制品，其中159例接受了UMT（0.23%；154例年龄在18 - 90岁，5例年龄在9 - 17岁），81%达到止血比例。总体死亡率为65%（n = 103）；平均ISS = 40；中位死亡时间为6.1小时。在单变量分析中，死亡与年龄、性别或超过20单位的更多RBC输注无关，但与钝性损伤、损伤严重程度增加、严重头部损伤以及未接受止血性血液制品比例有关。死亡率还与入院时pH值降低和凝血功能障碍的证据有关，尤其是低纤维蛋白原血症。多变量逻辑回归显示，严重头部损伤、入院时低纤维蛋白原血症以及未接受止血复苏比例的血液制品与死亡独立相关。
我们中心每420例急性创伤患者中有1例接受UMT，这是一个历史低发生率。这些患者中有三分之一存活，UMT本身并非徒劳的标志。早期识别凝血功能障碍是可能的，未按止血比例给予血液成分与过高死亡率相关。
