Acute blood loss during burn and soft tissue excisions: An observational study of blood product resuscitation practices and focused review.
Acute blood loss during burn and soft tissue excisions: An observational study of blood product resuscitation practices and focused review.
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DOI：
10.1097/ta.0000000000000627
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发表时间：
2015-06
期刊：
影响因子：
--
通讯作者：
Cap AP
中科院分区：
文献类型：
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作者：
Pidcoke HF;Isbell CL;Herzig MC;Fedyk CG;Schaffer BS;Chung KK;White CE;Wolf SE;Wade CE;Cap AP
许多军事和民用中心已转向损害控制复苏（DCR）方法，重点是提供携氧能力，同时通过平衡血小板和血浆与红细胞的比例来缓解凝血病。目前还不清楚在烧伤或软组织切除术中使用这种策略的程度。在这里，我们描述了烧伤和软组织手术期间血液制品输注的特点，并回顾了有关术中凝血变化的已发表文献。我们假设，在烧伤和软组织切除术期间，血液制品复苏不能止血，不足以解决烧伤诱导的凝血功能障碍。入选的成人患者参加了IRB批准的前瞻性观察性研究。在烧伤切除/移植或软组织清创术期间记录输注的血液制品的数量、成分类型、体积和年龄。收集组分袋（pRBC、FFP、PLT和冷沉淀物），并从袋和管路中收获剩余样品。取每种血液制品原始体积的1/1000等分试样并合并，产生含有相同比例输注产品的汞合金样品。测量血小板计数、旋转血栓弹性测定法和阻抗聚集测定法。显著性设定为p<0.05。合并的输血液样本产生异常弱的凝块（p≤0.001），特别是如果它们不含血小板。含血小板汞合金的凝块强度（48.8 ± 2.6 mm;参考范围：49- 71 mm）低于参考范围的下限，尽管PLT：RBC比大于1：1。血小板聚集率异常低;输注血小板的功能劣于天然血小板。我们的研究和重点审查表明，需要进一步的工作，以充分了解接受组织切除的患者的需求。回顾的三项研究和我们的观察工作结果表明，凝血障碍和血小板减少症可能导致术中出血。在烧伤和软组织切除时，血液制品复苏不能止血。
Many military and civilian centers have shifted to a Damage Control Resuscitation (DCR) approach, focused on providing oxygen-carrying capacity while simultaneously mitigating coagulopathy with a balanced ratio of platelets and plasma to red blood cells. It is unclear to what degree this strategy is used during burn or soft tissue excision. Here we characterized blood product transfusion during burn and soft tissue surgery, and reviewed the published literature regarding intraoperative coagulation changes. We hypothesized that blood product resuscitation during burn and soft tissue excision is not hemostatic and would be insufficient to address hemorrhage-induced coagulopathy. Consented adult patients were enrolled into an IRB-approved prospective observational study. Number, component type, volume, and age of the blood products transfused were recorded during burn excision/grafting or soft tissue debridement. Component bags (pRBCs, FFP, PLTs, and cryoprecipitate) were collected and the remaining sample harvested from the bag and tubing. Aliquots of 1/1000th the original volume of each blood product were obtained and combined, producing an amalgam sample containing the same ratio of product transfused. Platelet count, rotational thromboelastometry, and impedance aggregometry were measured. Significance was set at p<0.05. Amalgamated transfusate samples produced abnormally weak clots (p≤0.001) particularly if they did not contain platelets. Clot strength (48.8 ± 2.6 mm; reference range: 49–71mm) for platelet-containing amalgams was below the lower limit of the reference range despite PLT:RBC ratios greater than 1:1. Platelet aggregation was abnormally low; transfused platelets were functionally inferior to native platelets. Our study and focused review demonstrate that further work is needed in order to fully understand the needs of patients undergoing tissue excision. The three studies reviewed and the results of our observational work suggest that coagulopathy and thrombocytopenia may contribute to intraoperative hemorrhage. Blood product resuscitation during burn and soft tissue excision is not hemostatic.