心脏手术中的大量输血：血液成分比例对临床结局和生存率的影响
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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
心脏手术是医学发达国家大规模输血的最常见背景。损伤后大量输血的研究表明，输入的血浆和血小板（PLT）与红细胞（RBCs)）的比例会影响死亡率。来自红细胞贮存时间研究（RECESS）的数据——一项关于复杂心脏手术患者红细胞储存时间影响的大型随机试验，被用来回顾性地分析了大量输血患者血成分比例与临床预后的关系。
方 法
大量输血的定义为≥6 单位RBC或≥8单位总成分血。对血浆而言，高比率被定义为≥1单位血浆：1单位红细胞；对血小板而言，高比率被定义为≥0.2 PLT剂量：1单位RBC，PLT剂量定义为1单采血小板或5全血血小板等值。用以分析的临床结果有死亡率和多器官功能障碍评分（ΔMODS）的变化——死亡的最早期，出院时，7天后与术前综合得分最高值相比。对高比率和低比率输血患者的结果进行比较，线性和Cox回归被用来探讨预测因子和连续结果及时间到事件的结果之间的关系。
结 果
总共有324名受试者符合大规模输血的定义。在那些接受高血浆：RBC比率的患者，和低比率患者相比，7天和28天ΔMODS平均值（标准误差）分别低1.24（0.45）及1.26（0.56）分（P = .007 和 P = .024）。在接受高血小板剂量：RBC比率的患者，7天和28天ΔMODS平均值（标准误差）分别低1.55（0.53）及1.49（0.65）分（P = .004和P = .022）。与接受率高者相比，接受低血浆：RBC比例输血的受试者的7天死亡率更高（后者7.2%比前者1.7%， P=.0318），而28天更加显著（P = .035）。血小板：红细胞比率与死亡率差异不相关。
结 论
这项分析发现，在接受大量输血的复杂心脏手术患者，使用的血液产品的组分和临床转归之间有关联。具体来说，那些接受高比例输血的患者发生器官功能障碍的较少（血浆：红细胞和血小板：红细胞），接受高血浆：红细胞比率输血的患者死亡率较低。
原始文献摘要
Delaney, Meghan DO; Stark, Paul C. MS; Suh, Minhyung ; Anesthesia & Analgesia.2017 ,124 (6)1777–1782
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 surgery, 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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