无法通过4小时的输血容量和速率来预测出血性创伤患者的治疗无效性。
The inability to predict futility in hemorrhaging trauma patients using 4-hour transfusion volumes and rates.
作者信息
Van Gent Jan-Michael, Clements Thomas W, Rosario-Rivera Bedda L, Wisniewski Stephen R, Cannon Jeremy W, Schreiber Martin A, Moore Ernest E, Namias Nicholas, Sperry Jason L, Cotton Bryan A
机构信息
From the Department of Surgery (J.-M.V., T.W.C., B.A.C.), McGovern Medical School, University of Texas Health Science Center, Houston, Texas; Department of Epidemiology (B.L.R.-R., S.R.W.) and Department of Surgery (J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Donald D. Trunkey Center for Civilian and Combat Casualty Care (M.A.S.), Oregon Health & Science University, Portland, Oregon; Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health (E.E.M.), University of Colorado Health Sciences Center, Denver, Colorado; Department of Surgery (N.N.), University of Miami/Jackson Memorial Hospital, Miami, Florida; and Department of Surgery (J.L.S.), Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania.
出版信息
J Trauma Acute Care Surg. 2025 Feb 1;98(2):236-242. doi: 10.1097/TA.0000000000004541. Epub 2025 Jan 6.
BACKGROUND
Blood shortages and utilization stewardship have motivated the trauma community to evaluate futility cutoffs during massive transfusions (MTs). Recent single-center studies have confirmed meaningful survival in ultra-MT (≥20 U) and super-MT (≥50 U), while others advocate for earlier futility cut points. We sought to evaluate whether transfusion volume and intensity cut points could predict 100% mortality in a multicenter analysis.
METHODS
A prospective, multicenter, observational cohort study was performed at seven trauma centers. Injured patients at risk for MT who required both blood transfusion and hemorrhage control procedures were enrolled. Four-hour volumes and intensities (average units per hour) were evaluated. Primary outcome of interest was 28-day mortality.
RESULTS
A total of 1,047 patients met the study inclusion with an overall mortality rate of 17% (n = 176). The median age was 35 years, 80% were male, and 62% had a penetrating mechanism, with an Injury Severity Score of 22. At 4 hours, transfusion volumes below 110 U and transfusion intensity averaging up to 21 U/h did not demonstrate futility. Total transfusion volume above 110 U was associated with 100% mortality (n = 9). Multivariable analysis noted only nonmodifiable risk factors as predictors of increased mortality (blunt mechanism, shock index).
CONCLUSION
In this study from seven Level 1 trauma centers, survival was observed at transfusion volumes up to 110 U and at transfusion velocities up to 21 U/h during the first 4 hours of resuscitation. Data are limited on transfusion volumes above 110 U in the first 4 hours. Survival can be observed in both the ultra and super-MT settings.
LEVEL OF EVIDENCE
Therapeutic/Care Management; Level II.
背景
血液短缺和合理用血管理促使创伤学界评估大量输血（MT）期间的无效临界点。近期的单中心研究证实，在超大量输血（≥20单位）和超大输血（≥50单位）情况下仍有显著的生存情况，而其他研究则主张更早的无效临界点。我们试图在多中心分析中评估输血量和输血强度临界点是否能预测100%的死亡率。
方法
在七个创伤中心进行了一项前瞻性、多中心、观察性队列研究。纳入有MT风险且需要输血和出血控制程序的受伤患者。评估4小时的输血量和输血强度（每小时平均单位数）。主要关注的结局是28天死亡率。
结果
共有1047例患者符合研究纳入标准，总死亡率为17%（n = 176）。中位年龄为35岁，80%为男性，62%为穿透性损伤机制，损伤严重程度评分为22分。在4小时时，输血量低于110单位且平均输血强度高达21单位/小时并未显示为无效。总输血量超过110单位与100%的死亡率相关（n = 9）。多变量分析指出，只有不可改变的风险因素是死亡率增加的预测因素（钝性损伤机制、休克指数）。
结论
在这项来自七个一级创伤中心的研究中，在复苏的前4小时内，输血量高达110单位和输血速度高达21单位/小时时观察到了生存情况。关于前4小时内输血量超过110单位的数据有限。在超大量输血和超大输血情况下均可观察到生存情况。
证据级别
治疗/护理管理；二级。
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