台大醫院大量輸血流程分析

Implementing a Massive Transfusion Protocol at NTUH

背景：近年面對大量輸血的議題，國際指引建議輸注之血液成份達一定比例，尤其是針對血漿（FreshFrozen Plasma, FFP）與紅血球間有較高的比值、或是需要及時送達血液至需大量輸血的病人。多數醫院已陸續建立大量輸血流程（Massive Transfusion Protocol, MTP），以提供快速跨部門的輸血服務，台大醫院血庫近期與急診醫學部合作，共同建構電腦輔助之大量輸血流程以利大量輸血照護。研究方法：以回溯性觀察研究方式，收集2016年9月MTP流程建立前18個月之緊急輸血及建立後18個月啟動MTP之病患，分析這段期間血液輸注量符合大量輸血者，研究統計MTP實施前後，臨床醫療使用血品及血庫供血的差異性，並分析單一或多重變異因素對死亡率的影響。主要結論：實施MTP後，臨床醫療使用FFP及血小板（Platelet, PLT）人數較MTP前顯著增加（p <0.001及0.004），血庫因預先解凍FFP，MTP後供血時間明顯加速（20 vs 6.5 mins, p <0.001）。完全啟動MTP流程顯示其相較於無電腦輔助之大量輸血的死亡率間有顯著降低之差異（p=0.00372）。以單一變數分析影響死亡因素包括年紀、Lactic acid（p <0.041及0.005）及是否有輸注FFP （p =0.091）；以多變數分析所有病人，Lactic acid（odds ratio 1.157; 95% CI 1.044-1.283; p = 0.005）具顯著意義，就非創傷病人多變數分析住院中死亡之相關因素，除Lactic acid（p =0.022）具顯著意義外，FFP於10分鐘內發血（p =0.054）和PLT輸注（p =0.076）則接近統計意義。結論：實施電腦輔助的流程可達到較佳的FFP和PLT使用，並改善大量出血的凝血功能，經由此研究發現，MTP不僅適用創傷病人，也適用於非創傷病人，其能提高病人存活率。 Background: Current massive transfusion guideline recommends balanced transfusion, i.e. higherplasma-red cell transfusion ratio, and timely delivery of blood products for patients requiringmassive transfusion. Most hospitals have begun to set up massive transfusion protocol (MTP) toprovide a rapid coordinated transfusion service. Departments of laboratory medicine andemergency medicine of National Taiwan University Hospital recently collaborated on acomputer-assisted MTP to facilitate the massive transfusion procedure.Study Design and Methods: This retrospective study aimed to compare patient outcome andquantity indicators 18 months before and after the implementation of the computer-assistedprotocol.Results: The protocol resulted in a significant increase in use of plasma and platelet components (p<0.001& 0.004) and a decrease in time to release of plasma (20 vs 6.5 mins, p <0.001). Fullyactivated MTP has shown to decrease mortality than no computer-assisted MTP (p=0.00372).Univariate logistic regression analysis identified age (odds ratio 1.026; 95% CI 1.001-1.051; p =0.041), lactic acid (odds ratio 1.136; 95% CI 1.038-1.2436; p = 0.005) as predictors for in-hospitalmortality, and transfusions of plasma (odds ratio 0.476; 95% CI 0.201-1.126; p = 0.091) impliedsurvival benefit. When performing multiple logistic regressions model, only lactic acid (odds ratio1.157; 95% CI 1.044-1.2483; p = 0.005) had a statistical significance with in-hospital mortality.Conclusion: The implementation of computer-assisted MTP can achieve a better utilization inplasma and platelet and avert coagulopathy in patients suffering hemorrhage. It seems to besuitable for both trauma and non-trauma patients.