治疗性血浆置换对于创伤性凝血病的重伤患者是可行且可耐受的。
Therapeutic plasma exchange is feasible and tolerable in severely injured patients with trauma-induced coagulopathy.
作者信息
Moore Sarah A, Rollins-Raval Marian A, Gillette Jennifer M, Kiss Joseph E, Triulzi Darrell J, Yazer Mark H, Paul Jasmeet S, Leeper Christine M, Neal Matthew D, Raval Jay S
机构信息
Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA.
Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA.
出版信息
Trauma Surg Acute Care Open. 2024 Jan 5;9(Suppl 1):e001126. doi: 10.1136/tsaco-2023-001126. eCollection 2024.
OBJECTIVES
Trauma-induced coagulopathy (TIC) occurs in a subset of severely injured trauma patients. Despite having achieved surgical hemostasis, these individuals can have persistent bleeding, clotting, or both in conjunction with deranged coagulation parameters and typically require transfusion support with plasma, platelets, and/or cryoprecipitate. Due to the multifactorial nature of TIC, targeted interventions usually do not have significant clinical benefits. Therapeutic plasma exchange (TPE) is a non-specific modality of removing and replacing a patient's plasma in a euvolemic manner that can temporarily normalize coagulation parameters and remove deleterious substances, and may be beneficial in such patients with TIC.
METHODS
In a prospective case series, TPE was performed in severely injured trauma patients diagnosed with TIC and transfusion requirement. These individuals all underwent a series of at least 3 TPE procedures performed once daily with plasma as the exclusive replacement fluid. Demographic, injury, laboratory, TPE, and outcome data were collected and analyzed.
RESULTS
In total, 7 patients received 23 TPE procedures. All patients had marked improvements in routine coagulation parameters, platelet counts, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activities, inflammatory markers including interleukin-6 concentrations, and organ system injuries after completion of their TPE treatments. All-cause mortality rates at 1 day, 7 days, and 30 days were 0%, 0%, and 43%, respectively, and all patients for whom TPE was initiated within 24 hours after injury survived to the 30-day timepoint. Surgical, critical care, and apheresis nursing personnel who were surveyed were universally positive about the utilization of TPE in this patient population. These procedures were tolerated well with the most common adverse event being laboratory-diagnosed hypocalcemia.
CONCLUSION
TPE is feasible and tolerable in severely injured trauma patients with TIC. However, many questions remain regarding the application of TPE for these critically ill patients including identification of the optimal injured population, ideal time of treatment initiation, appropriate treatment intensity, and concurrent use of adjunctive treatments.
LEVEL OF EVIDENCE
Level V.
目的
创伤性凝血病（TIC）发生于部分严重受伤的创伤患者中。尽管已实现手术止血，但这些患者仍可能持续出血、凝血，或两者兼有，同时伴有凝血参数紊乱，通常需要输注血浆、血小板和/或冷沉淀进行支持治疗。由于TIC具有多因素性质，针对性干预通常没有显著的临床益处。治疗性血浆置换（TPE）是以等容方式去除和替换患者血浆的一种非特异性治疗方法，可使凝血参数暂时恢复正常并去除有害物质，可能对这类TIC患者有益。
方法
在一项前瞻性病例系列研究中，对诊断为TIC且有输血需求的严重受伤创伤患者进行TPE治疗。这些患者均接受了一系列至少3次TPE治疗，每天进行1次，仅用血浆作为置换液。收集并分析了人口统计学、损伤情况、实验室检查、TPE治疗及结局数据。
结果
共有7例患者接受了23次TPE治疗。所有患者在完成TPE治疗后，常规凝血参数、血小板计数、含Ⅰ型血小板反应蛋白基序的解聚素和金属蛋白酶13（ADAMTS13）活性、包括白细胞介素-6浓度在内的炎症标志物以及器官系统损伤均有显著改善。1天、7天和30天的全因死亡率分别为0%、0%和43%，所有在受伤后24小时内开始TPE治疗的患者均存活至30天时间点。接受调查的外科、重症监护和血液分离护理人员对在该患者群体中使用TPE普遍持肯定态度。这些治疗耐受性良好，最常见的不良事件是实验室诊断的低钙血症。
结论
TPE在患有TIC的严重受伤创伤患者中是可行且可耐受的。然而，关于TPE在这些重症患者中的应用仍有许多问题，包括最佳受伤人群的识别、理想的治疗起始时间、合适的治疗强度以及辅助治疗的联合使用。
证据级别
V级。
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