A Paradigm Shift in Trauma Resuscitation Evaluation of Evolving Massive Transfusion Practices
A Paradigm Shift in Trauma Resuscitation Evaluation of Evolving Massive Transfusion Practices
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DOI：
10.1001/jamasurg.2013.2911
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发表时间：
2013-09-01
期刊：
影响因子：
16.9
通讯作者：
Cohen, Mitchell J.
中科院分区：
文献类型：
--
作者：
Kutcher, Matthew E.;Kornblith, Lucy Z.;Cohen, Mitchell J.
重要性损伤控制策略的发展导致了创伤性损伤后复苏方法的显著变化，目的评估液体和血液制品给药的变化，假设在过去的7年中，晶体体积的减少和红细胞（RBC）与新鲜冷冻血浆（FFP）比值的降低与更好的复苏结局相关。地点：市区一级创伤中心。对象：174例接受大量输血的创伤患者（24小时内>10个单位的红细胞）或需要启动机构大量输血方案。暴露患者必须接受大量输血或需要启动机构大量输血方案。结果：平均（SD）损伤严重度评分为28.4（16.2），平均（SD）基础缺陷为-9.8（6.3），中位数国际标准化比率为1.3（四分位数范围，1.2-1.6）;死亡率为40.8%。患者在24小时内接受了中位数为6.1 L的晶体、13个单位的RBC、10个单位的FFP和1个单位的血小板，平均RBC：FFP比为1.58：1。在研究期间，平均24小时晶体输注量和前24小时内给予的总血液制品单位数显著降低（P <0.05）。RBC：FFP比值从2007年的峰值1.84：1降至2011年的1.55：1（P = .20）。损伤严重程度和死亡率在研究期间保持稳定。当使用考克斯回归对年龄和损伤特征进行调整时，大量输血方案的RBC：FFP比率每降低0.1，死亡率降低5.6%（P = 0.005）。结论和相关性在复苏过程中，已经出现了向减少晶体体积和从成分产品中重建全血的转变。这些变化与显著改善的结果和严重损伤患者复苏的新模式相关。
IMPORTANCE The evolution of damage control strategies has led to significant changes in the use of resuscitation after traumatic injury.OBJECTIVE To evaluate changes in the administration of fluids and blood products, hypothesizing that a reduction in crystalloid volume and a reduced red blood cell (RBC) to fresh frozen plasma (FFP) ratio over the last 7 years would correlate with better resuscitation outcomes.DESIGN Observational prospective cohort study. SETTING Urban level I trauma center.PARTICIPANTS A total of 174 trauma patients receiving a massive transfusion (>10 units of RBCs in 24 hours) or requiring the activation of the institutional massive transfusion protocol from February 2005 to June 2011.EXPOSURE Patients had to either receive a massive transfusion or require the activation of the institutional massive transfusion protocol.MAIN OUTCOMES AND MEASURES In-hospital mortality.RESULTS The mean (SD) Injury Severity Score was 28.4 (16.2), the mean (SD) base deficit was -9.8 (6.3), and median international normalized ratio was 1.3 (interquartile range, 1.2-1.6); the mortality rate was 40.8%. Patients received a median of 6.1 L of crystalloid, 13 units of RBCs, 10 units of FFP, and 1 unit of platelets over 24 hours, with a mean RBC:FFP ratio of 1.58:1. The mean 24-hour crystalloid infusion volume and number of the total blood product units given in the first 24 hours decreased significantly over the study period (P < .05). The RBC:FFP ratio decreased from a peak of 1.84:1 in 2007 to 1.55:1 in 2011 (P = .20). Injury severity and mortality remained stable over the study period. When adjusted for age and injury characteristics using Cox regression, each decrease of 0.1 achieved in the massive transfusion protocol's RBC:FFP ratio was associated with a 5.6% reduction in mortality (P = .005).CONCLUSIONS AND RELEVANCE There has been a shift toward a reduced crystalloid volume and the recreation of whole blood from component products in resuscitation. These changes are associated with markedly improved outcomes and a new paradigm in the resuscitation of severely injured patients.