心脏外科手术中大量输血：血液成分比例对临床结局和存活率的影响
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Massive Transfusion in Cardiac Surgery: The Impact of Blood Component Ratios on Clinical Outcomes and Survival
背景与目的
医学发达国家心脏外科手术常存在大量输血。机体损伤常给予大量输血，研究表明给予的血浆和血小板（PLT）与红细胞（RBC）的比例对死亡率有影响。本回顾性分析来自红细胞储存期限研究（RECESS）的数据，大量关于红细胞储存期限对经历复杂心脏病患者的影响的随机试验以研究大量输血患者中使用不同的血液成分比率与随之的临床结局之间的关联性。
方 法
大量输血定义为输入≥6单位 RBC或≥8全血。对于血浆，高比例定义为≥1单位血浆：1单位RBC。对于输入血小板，高比率定义为≥0.2 PLT剂量：1单位RBC；PLT剂量定义为1单采血小板或5全血PLT当量。临床结局分析死亡率及多器官功能障碍评分的变化（ΔMODS），通过对早期死亡，出院或出院第7天对术前评分与最高综合评分进行比较。结局指标是病人输入高、低比例之间的比较。线性和Cox回归被用于探讨预测指标、连续结果和时间到事件结果之间的关系.
结 果
共有324名受试者符合大量输血。在这些接受高比率血浆：RBC的患者中、平均（SE）7天、28天ΔMODS是1.24（0.45）和1.26（0.56），分别比接受低比率的低（P = 007，P = 024）。在接收高比率PLT:RBC的患者中，平均（SE）7天、28天ΔMODS 分别是1.55（0.53）和1.49（0.65）分别比接受低比率的低（P = 004，P = 022）。接受低比率血浆：RBC的患者与高比率相比，7天以上（分别为7.2%和1.7%，P＝0318）和28天内的死亡率仍然显著（P = 035）。血小板：RBCs的比率与死亡率之间无关联性。
结 论
这项分析发现，在接受大量输血的复杂心脏手术患者中，血液制品的组成与临床结局之间存在关联性。具体来说，接受高比例输血(血浆:RBCs and PLT:RBCs),的患者的器官功能障碍较少，而接受高比例（血浆:RBC）患者的死亡率较低。
原始文献摘要
Delaney M1,Stark PC，Suh M，et al.Massive Transfusion in Cardiac Surgery: The Impact of Blood Component Ratios on Clinical Outcomes and Survival.Anesth Analg.2017 Jun;124(6):1777-1782.doi:10.1213/ANE. 0000000000001926.
BACKGROUND: Cardiac surgery is the most common setting for massive transfusion in medically advanced countries. Studies of massive transfusion after injury suggest that the ratios of administered plasma and platelets(PLT) to red blood cells(RBCs) affect mortality.Data from the Red Cell Storage Duration Study (RECESS),a large randomized trial of the effect of RBC storage duration in patients undergoing complex cardiac, were analyzed retrospectively to investigate the association between blood component ratios used in massively transfused patients and subsequent clinical outcomes.
METHODS: Massive transfusion was defined as those who had≥6 RBC units or≥8 total blood components.For plasma,high ratio was defined as≥1 plasma unit:1 RBC unit.For PLT transfusion,high ratio was defined as≥0.2 PLT doses:1 RBC unit;PLT dose was defined as 1 apheresis PLT or 5 whole blood PLT equivalents.The clinical outcomes analyzed were mortality and the change in the Multiple Organ Dysfunction Score(ΔMODS) comparing the preoperative score with the highest composite score through the earliest of death,discharge,or day 7.Outcomes were compared between patients transfused with high and low ratios.Linear and Cox regression were used to explore relationships between predictors and continuous outcomes and time to event outcomes.
RESULTS: A total of 324 subjects met the definition of massive transfusion. In those receiving high plasma:RBC ratio, the mean (SE) 7- and 28-day ΔMODS was 1.24(0.45) and 1.26(0.56) points lower,(P=.007 and P=.024), respectively,than in patients receiving lower ratios.In patients receiving high PLT:RBC ratio, the mean (SE) 7- and 28-day ΔMODS were 1.55 (0.53) and 1.49(0.65) points lower(P=.004 and P=.022),respectively. Subjects who received low-ratio plasma:RBC transfusion had excess 7-day mortality compared with those who received high ratio(7.2% vs 1.7%, respectively,P = .0318),which remained significant at 28 days (P = .035). The ratio of PLT:RBCs was not associated with differences in mortality.
CONCLUSIONS:This analysis found that in complex cardiac surgery patients who received massive transfusion, there was an association between the composition of blood products used and clinical outcomes.Specifically, there was less organ dysfunction in those who received high-ratio
transfusions (plasma:RBCs and PLT:RBCs）,and lower mortality in those who received high-ratio plasma:RBC transfusions.
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