Respicio Jessicah A, Culhane John
Department of Trauma and Surgical Critical Care, St. Louis University Hospital, St. Louis, MO, USA.
J Emerg Trauma Shock. 2023 Apr-Jun;16(2):54-58. doi: 10.4103/jets.jets_146_22. Epub 2023 May 23.
Selective nonoperative management (NOM) is the standard of care for blunt solid organ injury (SOI). Hemodynamic instability is a contraindication for NOM, but it is unclear whether the need for blood transfusion should be a criterion for instability. This study looks at the outcome of blood-transfused SOI patients to determine whether NOM is safe for this group.
This is a retrospective cohort study using the National Trauma Data Bank years 2017 through 2019. We selected patients with blunt liver, spleen, and kidney injuries. Within this group, we compared the mortality for those managed with NOM versus the hemostatic procedures of laparotomy and angioembolization. Significance for univariate analysis is tested with Chi-square for categorical variables. Multivariate analysis is performed with Cox proportional hazards regression with time-dependent covariate.
108,718 (3.5%) patients for the years 2017 through 2019 had a SOI. 20,569 (18.9%) of these received at least one unit of packed red blood cells (PRBCs) within the first 4 h. Of the SOI patients who received blood, 8264 (40.2%) underwent laparotomy only, 2924 (14.2%) underwent embolization only, and 1119 (5.4%) underwent both procedures. The adjusted odds ratios (ORs) of death for transfused SOI patients who underwent laparotomy only, embolization only, and both procedures are 0.93 ( = not significant), 0.27 ( < 0.001), and 0.48 ( < 0.001), respectively. The ORs of death with laparotomy for patients receiving >1 through 4 units are 0.87, 0.78, 0.75, and 0.72, respectively ( ≤ 0.01 for all). For embolization, the ORs are 0.27, 0.30, 0.30, and 0.30, respectively ( < 0.001 for all).
Laparotomy is independently associated with survival for patients who receive >1 unit of PRBCs. Angioembolization is independently associated with survival for the entire cohort, including transfused patients. Given the protective association of laparotomy in the blood-transfused SOI group, need for blood transfusion should be considered a meaningful index of instability and a relative indication for laparotomy. The protective association with angioembolization supports current practices for angioembolization of high-risk patients in the transfused and nontransfused groups.
选择性非手术治疗（NOM）是钝性实性器官损伤（SOI）的标准治疗方法。血流动力学不稳定是NOM的禁忌症，但输血需求是否应作为不稳定的标准尚不清楚。本研究观察输血的SOI患者的结局，以确定NOM对该组患者是否安全。
这是一项回顾性队列研究，使用2017年至2019年的国家创伤数据库。我们选择了钝性肝、脾和肾损伤患者。在该组患者中，我们比较了接受NOM治疗的患者与剖腹手术和血管栓塞止血手术患者的死亡率。分类变量的单因素分析显著性用卡方检验。多因素分析采用Cox比例风险回归和时间依赖性协变量。
2017年至2019年期间，108718名（3.5%）患者发生了SOI。其中20569名（18.9%）患者在最初4小时内接受了至少1单位的浓缩红细胞（PRBCs）。在接受输血的SOI患者中，8264名（40.2%）仅接受了剖腹手术，2924名（14.2%）仅接受了栓塞治疗，1119名（5.4%）接受了两种手术。仅接受剖腹手术、仅接受栓塞治疗以及接受两种手术的输血SOI患者的调整后死亡比值比（OR）分别为0.93（=无显著性）、0.27（<0.001）和0.48（<0.001）。接受1至4单位输血的患者进行剖腹手术的死亡OR分别为0.87、0.78、0.75和0.72（均≤0.01）。对于栓塞治疗，OR分别为0.27、0.30、0.30和0.30（均<0.001）。
剖腹手术与接受>1单位PRBCs的患者的生存独立相关。血管栓塞与整个队列（包括输血患者）的生存独立相关。鉴于剖腹手术在输血的SOI组中的保护作用，输血需求应被视为不稳定的有意义指标和剖腹手术的相对指征。血管栓塞的保护作用支持了目前对输血和未输血高危患者进行血管栓塞的做法。
