创伤患者超大量输血的回顾性研究：是否存在一个输血阈值，超过该阈值后额外输血便徒劳无功？

A Retrospective Study of Ultramassive Transfusion in Trauma Patients: Is There a Value After Which Additional Transfusions Are Futile?

作者信息

Major Frank R, Pickering Trevor A, Stefanescu Kristen, Singh Mandeep, Clark Damon H, Inaba Kenji, Nahmias Jeffry T, Tay-Lasso Erika L, Alvarez Claudia, Chen Joy L, Ahmed Farzin, Kaslow Olga Y, Tong Jeffrey L, Xiao Jianzhou, Hall Elizabeth, Elkhateb Rania, Bahgat Youssef, Tatum Danielle, Simpson John T, Singh Siddharth, Klein Norma J, Applegate Richard L, Kuza Catherine M

机构信息

From the Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, California.

Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California.

出版信息

Anesth Analg. 2025 May 30. doi: 10.1213/ANE.0000000000007569.

DOI:10.1213/ANE.0000000000007569

PMID:40445862

Abstract

BACKGROUND

Hemorrhage is a leading cause of preventable mortality in trauma. During times of blood shortages, it may be prudent to consider a transfusion threshold during massive transfusion after which additional transfusions are futile due to nonsurvivability. The main objective of this study is to examine outcomes associated with ultramassive transfusion (UMT; defined as ≥20 units of red blood cells [RBC] within 24 hours) and determine if there is a threshold beyond which additional transfusion efforts should cease.

METHODS

We performed a retrospective (2016-2022) analysis of adult trauma patients (≥ 18 years old) who underwent surgery and received blood products within 24 hours of admission at 7 US Level I trauma centers. We compared patients who received UMT and patients who received <20 units RBC and evaluated the effects of various amounts of blood products on mortality, length of stay (LOS), mechanical ventilation (MV), and complications. Segmented logistic regression analysis was performed to determine if there is a "plateau" effect of increasing RBC units on mortality.

RESULTS

Of 3248 patients included, 2913 (89.7%) received <20 RBC units within 24 hours, and 333 (10.3%) received ≥20 RBC units within 24 hours. Patients receiving UMT had increased 24-hour mortality (risk ratio [RR] 6.00, 95% confidence interval [CI], 4.79-7.52, P < .001) and index hospitalization mortality (RR 3.99 [3.34-4.75], P < .001). These patients also more often developed complications (RR 1.67 [1.44-1.94], P < .001) and multiple organ failure (RR 2.78 [2.20-3.52], P < .001). Compared to those receiving 20 to 29 RBC units, those receiving 30 to 44 RBC units had statistically similar associated risk of death (RR 1.32 [0.93-1.87], P = .12); however, those receiving ≥45 RBC units had an increased associated risk of death (RR 1.59, [1.12-2.25], P = .009), and additional transfusion beyond this point did not improve the probability of survival.

CONCLUSIONS

In this study, patients who received UMT had higher mortality and worse outcomes than those who received fewer units. However, this study did not identify a threshold beyond which all patients died and therefore cannot justify implementing a limit on the number of RBC units transfused based on these data alone.

摘要

背景

出血是创伤中可预防死亡的主要原因。在血液短缺时期，考虑在大量输血期间设定一个输血阈值可能是明智的，超过该阈值后，由于无法存活，额外输血将徒劳无功。本研究的主要目的是检查与超大量输血（UMT；定义为24小时内输注≥20单位红细胞[RBC]）相关的结果，并确定是否存在一个阈值，超过该阈值应停止额外的输血努力。

方法

我们对7家美国一级创伤中心收治的成年创伤患者（≥18岁）进行了回顾性（2016 - 2022年）分析，这些患者在入院后24小时内接受了手术并接受了血液制品。我们比较了接受UMT的患者和接受<20单位RBC的患者，并评估了不同数量的血液制品对死亡率、住院时间（LOS）、机械通气（MV）和并发症的影响。进行分段逻辑回归分析以确定增加RBC单位对死亡率是否存在“平台”效应。

结果

在纳入的3248例患者中，2913例（89.7%）在24小时内接受了<20单位RBC，333例（10.3%）在24小时内接受了≥20单位RBC。接受UMT的患者24小时死亡率增加（风险比[RR] 6.00，95%置信区间[CI]，4.79 - 7.52，P <.001），住院期间死亡率增加（RR 3.99 [3.34 - 4.75]，P <.001）。这些患者也更常发生并发症（RR 1.67 [1.44 - 1.94]，P <.001）和多器官功能衰竭（RR 2.78 [2.20 - 3.52]，P <.001）。与接受20至29单位RBC的患者相比，接受30至44单位RBC的患者死亡相关风险在统计学上相似（RR 1.32 [0.93 - 1.87]，P =.12）；然而，接受≥45单位RBC的患者死亡相关风险增加（RR 1.59，[1.12 - 2.25]，P =.009），超过这一点的额外输血并未提高生存概率。