TRAUMA ANESTHESIA SERIES (PART 3): BLOOD PRODUCTS, VASOPRESSORS & MASSIVE TRANSFUSION | EP47

欢迎回到《Atomic Anesthesia》播客的又一期节目。

Welcome back to another episode of the Atomic Anesthesia podcast.

本期是创伤与烧伤麻醉系列的第三部分。

This episode is part three of our Trauma and Burn Anesthesia series.

如果你还没听过第一和第二部分，先暂停一下，回去听完那两期，确保跟上进度。

If you haven't listened to part one and part two yet, pause this episode, go back, listen to those episodes, and so that you're all caught up.

这期我们会全面聊聊血液制品，顺便讲讲液体管理、你需要的设备、输血相关的并发症，还有那些在抢救患者时必须密切关注的实验室指标。

This episode, we're gonna talk all about blood products, a little bit about fluids, some equipment that you need, some transfusion related injuries, and some lab values that you're gonna need to pay close attention to in order to resuscitate your patient.

在严重创伤中，液体和血液管理有几个关键点。

So a couple things with fluid management and blood management in major trauma.

现在特别强调多用血液制品，少用晶体液，我们之前已经反复提过，这次会尽量避免使用大量晶体液。

There's a huge, huge emphasis on using blood products rather than crystalloids, and we've previously talked about this and harped on this that we're gonna get very little crystalloids.

我们会把重点放在血液制品上。

We're gonna really focus on those blood products.

包括输注浓缩红细胞、新鲜冰冻血浆、冷沉淀、血小板，以及任何其他需要的凝血因子。

So giving our packed red blood cells, our FFP, our fresh frozen plasma, cryoprecipitate, our platelets, any other coagulation factors that we need.

我们重点用这些血液制品，而不是大量输晶体液、胶体液，甚至血管活性药。

We're gonna focus on giving those things and less on giving crystalloids, colloids, or even vasopressors.

还有几点需要注意。

Couple other things to keep in mind.

我们需要评估患者的血管内血容量状态。

So we want a way to assess our intravascular volume status.

如果条件允许，房间里有经食道超声的话，就用它来观察心脏情况。

If you have the option to have a TEE in the room in order to look at the heart, use that.

比如监测每搏量变异度、脉压变异度，或者任何其他可用的先进设备，它们能帮你判断血容量情况——我们要做的是目标导向的液体管理，而不是凭感觉瞎猜。

Our stroke volume variation, pulse pressure variation, any other modern equipment or tech that's available that can give you some kind of indication of what the fluid status is because we wanna do more goal directed fluid therapy rather than guessing.

另外，我们也要关注一些关键的化验指标，比如动脉血气和乳酸水平，这些更能反映复苏效果，而不是只看血红蛋白和红细胞压积这类指标。

Also, we're gonna take a look at the lab values that are really important, like looking at more of your ABGs and your lactate level, which is going to indicate how well you're resuscitating your patients rather than looking at lab values like your hemoglobin and hematocrit.

如果条件允许且合适，我们也会考虑使用血液回收系统，比如细胞回收装置。

We're gonna consider any blood salvage systems if it's available and if it's appropriate, so using something like a cell saver device.

你得熟悉一些设备，比如 Belmont 机器或者 Level One 快速输液系统。

You wanna make sure you understand some of your devices like the Belmont machine or the level one rapid infusion machine.

一定要确保所有东西都预热好。

Wanna make sure we warm everything.

我们给的所有静脉输液和血液制品都要用加热设备 warming，千万别给病人输冷的东西，他们本来就体温偏低，所以所有液体都得是温的。

So warm all of our IV fluids that we give and our blood products using some kind of ranger device, making sure we're not giving our patients anything cold because they're already struggling with hypothermia, so we wanna make sure that everything is warm.

另一个要注意的原则是，必须密切监测钙离子水平。

Another principle to keep in mind is we wanna monitor the calcium levels really closely.

每输注两单位红细胞，就要再给一克氯化钙或葡萄糖酸钙，并持续监控钙水平，因为红细胞里用的枸橼酸盐抗凝剂会把体内的钙结合掉。

So continuing to give patients a gram of calcium chloride or gluconate every, you know, couple units of PRBCs and closely monitor the calcium levels because, like we mentioned, that citrate preservative that they put in the PRBCs, that's going to chelate all of the calcium or basically bind it up.

输血过程中，钙水平会迅速下降。

So the calcium levels are going to be quickly depleted as you're transfusing patients.

之前我们讲过损伤控制性复苏，很多关于复苏的知识其实都来自军方的经验。

Now we talked about resuscitation in previous episodes about damage control resuscitation, and a lot of the things that we understand about resuscitation we've learned from the military.

他们发现，输注全血的效果是最好的。

What they found is actually giving whole blood is the best.

全血在促进凝血方面比医院常用的成分输血更有效，但大多数情况下全血很难获得，因为没法长期保存。

Whole blood has the best maximal clotting formation versus what we typically do in the hospital, which is a component transfusion, but most of the time, whole blood is not going to be available because we can't store whole blood for a long period of time.

人们捐献的全血会被分离成不同的成分。

What happens with the whole blood that people donate is it gets divided into components.

它会被分成浓缩红细胞、新鲜冰冻血浆，然后从血浆里提取冷沉淀物，还有其他一些衍生制品，比如第七因子、第八因子这些都可以单独使用。

So it gets divided into packed red blood cells, it gets put into fresh frozen plasma, and then from that, we make cryoprecipitate, and from there, we have other, you know, derivatives from the FFP, like different factors, factor seven, factor eight that you can give as well.

我们输注血制品时，理想的配比是一比一比一。

So the ratio that we want to give blood products is one to one to one.

也就是一份浓缩红细胞配一份新鲜冰冻血浆，再配一份血小板。

So one unit of PRBCs to one unit of FFP to one unit of platelets.

就像我之前提到的，血小板通常会被集中装到一个袋子里。

And like I mentioned in previous episodes, the platelets are often pulled into one bag.

一般一袋血小板大约相当于六个单位的量。

So usually one bag of platelets is gonna be about six units.

所以每输六单位的红细胞和血浆，就要配一袋血小板。

So you're giving one bag of platelets for every six units of PRBCs and FFP.

最好跟医院的血库确认一下他们是怎么分装血小板的，不过多数情况下，一袋就是六个单位。

So just make sure you check with your hospital blood bank to understand how they pull their platelets, but a lot of times it's six units in one bag.

现在，浓缩红细胞和新鲜冰冻血浆都是冷藏出来的。

Now the PRBCs and the FFP will come up cold.

血小板则一直保持在室温。

Platelets always stay at room temperature.

我们还可以输注冷沉淀，通常是为了补充纤维蛋白原，或者用于血友病患者。

The other thing we can give is cryoprecipitate, and oftentimes we're giving cryoprecipitate specifically for fibrinogen supplementation or for patients that have hemophilia.

稍后我们会详细讲冷沉淀的成分，但先告诉你，我们的目标纤维蛋白原水平应该在150到200毫克每分升以上。

We'll talk about cryoprecipitate components in just a little bit, but just so you know, our target fibrinogen level should be above around one fifty to 200 milligrams per deciliter.

接下来我们聊聊血液制品的各个成分。

Now let's talk about the different components of blood products.

首先是浓缩红细胞。

So we have our PRBCs.

一袋浓缩红细胞的容量通常在200到300毫升左右，大家都知道它的作用和用途。

Oftentimes, the volume of that bag is around, you know, 200 to 300 mls, and we understand what PRBCs are and what they're for.

我们希望达到最佳的携氧能力，每输注一单位浓缩红细胞，血红蛋白会上升1克，血细胞比容会上升3%。

We want to have optimal oxygen carrying capacity, and for every one unit of PRBCs that you administer, that's going to increase your hemoglobin by one gram and increase your hematocrit by 3%.

我知道我们平时不常监测血红蛋白和红细胞压积，但作为一般原则，你的带教老师可能会问你这个问题，或者在考试中出现：每输注一单位红细胞，血红蛋白会上升1克，红细胞压积会上升3%。

I know we're not monitoring hemoglobin and hematocrit, but just as a general rule, you maybe get that as a question from your preceptor as a board question, it's going to increase hemoglobin by one gram and hematocrit by 3%.

但在创伤麻醉中，输注红细胞的主要目的是提高血液的携氧能力，让氧气能更好地输送到微循环和组织中。

But the main purpose of giving it during trauma anesthesia is to increase the oxygen carrying capacity of the blood in order to get it into microcirculation and deliver oxygen to the tissues.

至于血小板，如果你输注一袋六单位的血小板，体积大概也是300毫升左右，通常能提升血小板计数5到1万。

Now platelets, oftentimes if you're giving a six pack of platelets, which means six units in one bag, it's gonna be approximately 300 mls as well, and that's going to increase your platelets by about five to 10,000.

在复苏初期，我们不会太早大量输注血小板或冷沉淀。

Now in the early parts of resuscitation, we're not gonna really focus on giving a lot of platelets in the beginning or cryoprecipitate.

我们更关注的是浓缩红细胞和新鲜冰冻血浆。

We're gonna focus a little bit more on those packed red blood cells and the FFP.

等后面有了实验室结果，你就能看到血小板的实际水平了。

Eventually, you're going to get your lab values and see where your platelets run.

我一般的做法是，每输注六单位红细胞和新鲜冰冻血浆，就配合输注一袋血小板。

I typically are, you know, giving the platelets, like I said, for every six units of PRBCs and FFP, I'm going to give a pack of platelets.

等复苏情况逐渐稳定后，我会根据实验室指标来决定是否补充血小板。

As resuscitation becomes a little bit more stable, I'll give platelets based on the lab values.

如果血小板特别低，我就会补充血小板。

So if the platelets are really low, then I'm gonna supplement with platelets.

新鲜冰冻血浆的量差不多，大约是200到250毫升。

FFP, the volume is about the same, about 200 to two fifty.

新鲜冰冻血浆里含有所有的凝血因子。

Now FFP is gonna contain all of your coagulation factors.

它还包含所有的血浆蛋白。

It's gonna have all of your plasma proteins.

比如蛋白C、蛋白S，还有抗凝血酶III。

It's gonna have your protein c and your protein s and your antithrombin three.

它包含所有凝血因子，通常一袋能提升凝血因子水平约2%。

So it has all of your coagulation factors, and usually one bag is going to increase your coagulation factors by about 2%.

听起来不多，对吧。

Doesn't sound like a lot.

所以我们才要大量输注。

That's why we're giving a lot of it.

所以我们给FFP的量要和输红细胞的比例保持一致。

So we need to give that FFP in the same ratio that we're giving the PRBCs.

很多时候，我会同时挂上这两袋液体。

A lot of times, I'm hanging them at the same time.

我会用一条管路输红细胞，另一条输FFP，或者用快速输液装置把这两袋尽快输进去。

So I have one line that's got PRBCs going and one line that's got FFP going, or I have the rapid trans user that is putting those bags in as fast as possible.

冷沉淀的袋子小一些，我记得它含有第一、第八和第十三因子。

The cryoprecipitate, those bags are a little bit smaller, and the cryoprecipitate, the way that I remember it is it's going to have factors one, eight, and 13.

你想想这些因子的编号，正好是开头、中间和结尾。

And if you think about, like, the factor numbers, it's kind of has the beginning, the middle, and the end.

纤维蛋白原是第一因子，第八因子或者冯维勒布兰德因子在中间，第十三因子在最后。

So fibrinogen is factor one, and then it's gonna have factor eight or von Willebrand's factor, so that's in the middle, and then it's gonna have factor 13, that's at the end.

我是这么记的。

That's how I remember.

通常纤维蛋白原低于150，或者病人有血友病的时候，我们会用冷沉淀。

A lot of times we're giving cryoprecipitate when the fibrinogen is low, so less than one fifty, or if the patient has hemophilia.

血友病患者常常缺乏第八因子或冯·维勒布兰德因子，这也是我们使用冷沉淀的一个原因。

A lot of times with hemophilia, they're lacking in factor VIII or von Willebrand's factor, so that might be another reason why we would give cryoprecipitate.

一开始我们不会太关注冷沉淀和血小板，首要任务是尽快输注红细胞和新鲜冰冻血浆。

So not as big of a focus of cryoprecipitate and platelets in the beginning, we're gonna give those PRBCs and those FFP in the very beginning as fast as possible.

我们来聊聊大量输血方案，也就是MTP。

So let's talk a little bit about massive transfusion protocols or MTP.

所有创伤中心都有自己的大量输血方案，最好熟悉这套流程，并与血库保持良好沟通，知道什么时候该启动MTP。

Now all trauma centers have some kind of massive transfusion protocol, and it's a good idea to be pretty familiar with it and establish a pretty good communication with the blood bank, know when to make that call to switch to massive transfusion protocol.

MTP的正式定义是：24小时内输注超过10单位红细胞，或者1小时内输注4单位。

Now MTP is defined as giving over 10 of PRBCs in a twenty four hour period or four units in one hour.

这 technically 就是MTP的定义。

That's technically the definition of MTP.

但实际操作中，我通常在患者持续出血、知道马上需要一大箱血制品，或者患者持续低血压时就启动MTP。

But when you initiate MTP, a lot of times I'm initiating this when, you know, say we have a patient that's sanguinating, and I know I'm gonna need that big cooler of blood products right away, or if the patient has persistent hypotension.

患者血压低，而且对常规处理没什么反应。

So they're hypotensive, they're not responding to, you know, a couple measures.

我们还不清楚他们为什么血压低。

We don't know why they're hypotensive.

我们只能先假设他们体内有出血。

We're just gonna assume that they're hemorrhaging somewhere.

目前还不知道出血点在哪，所以先启动大量输血方案。

We just don't know where the hemorrhage is yet, so we're going to initiate the massive transfusion protocol.

大多数创伤中心都会备有O型阴性血，可以立即用于紧急输血。

Most trauma centers have, you know, this early release type o negative blood that's going to be available for immediate transfusion.

根据输血的紧急程度，通常会先用O型阴性血，等实验室完成血型鉴定和交叉配血后，再换成同型血。

And then depending on the urgency of the transfusion need, the blood product administration typically progresses from that o negative to the type specific blood after you're able to get a type and cross sent to the lab.

有趣的是，如果已经输了很多未经交叉配血的血液，通常建议继续使用O型阴性血，而不是切换到患者自身的血型。

Now interestingly, if you've already administered a large amount of uncross matched blood, It's usually recommended to continue on with the o negative blood rather than switching to the patient's native blood type.

这是因为，一旦输血量超过8单位左右，再换回患者自身血型反而会增加输血反应的风险，进而影响复苏效果和生存率。

The idea behind this is that at this point when you've administered beyond eight units or so, reverting back to the patient's native blood type in the situation is going to increase the risk of transfusion reactions, which can then complicate the resuscitation and the survival.

所以一开始先用O型阴性血，同时尽快把血型鉴定和交叉配血的样本送过去，争取尽早换成患者的同型血。

So in the beginning, you give the o negative blood, you try to get that type and cross down as soon as possible and get them to their native blood type.

但如果你已经输了很多O型阴性血，通常是八单位或更多，那就继续用O型阴性血吧。

But if you've already administered a large amount of o negative blood, usually eight or more units, then you should stick with the o negative blood.

MTP冷藏箱会送来一整箱血，里面通常包括六单位O型阴性浓缩红细胞。

Now MTP coolers, they send up this whole cooler of blood, and what it's going to contain usually is six units of type o negative PRBCs.

还会配六单位新鲜冰冻血浆，以及六单位血小板；在我们医院，是单包血小板，而且血型不限。

It's gonna have six units of fresh frozen plasma, and then six units of platelets, or in my institution, one pack of platelets, and that's gonna be any blood type.

我做过很多次MTP，必须强调，哪怕情况再混乱，也得保持极度有条理。

Now I will say with MTP, having done a lot of it, it's really important to stay super organized even when things seem really chaotic.

如果你在想，紧急情况下输血还得核对吗？

And, yes, if you're wondering, does blood still need to be checked even in an emergency?

是的，必须核对。

Yes, it does.

你得有个人专门陪你，尤其是在快速输血的时候，这个人只负责核对血液、挂血。

You need to have somebody there dedicated with you, especially if you're rapidly transfusing, that is going to just be doing the blood, checking the blood and hanging the blood.

有时候，这活儿得两个人一起干。

And sometimes this takes two people to do.

我会拿条毯子铺在地上，然后把血袋一排排摆好。

I'll take a blanket and I'll lay it down on the ground, and I'll just line up my blood bags that way.

这样我的红细胞悬液就能整整齐齐排成一行。

So I'll have my PRBCs kind of lined up in a row.

血浆、血小板袋、钙剂棒，全都在地上按顺序摆好。

I'll have my FFPs lined up in a row, my platelet bags, my sticks of calcium, all kind of organized on the ground.

因为到最后，你可能还得回头核对，甚至要把每袋血的编号都记进病历里。

Because sometimes after all of it is said and done, you have to go back through and sometimes even chart all of those bag numbers into your charting.

看起来确实会很乱。

So it seems really chaotic.

但一定要保持条理，确保输液管路也井然有序。

Stay organized, making sure that your lines are organized.

安排一到两个人专门负责输血操作。

Have one or two people dedicated to just transfusing products.

就像我之前说的，做这种大量输血，必须用上快速输血仪。

Like I mentioned, you're going to need some kind of rapid infuser in order to do this massive transfusion.

如果没有快速输注仪，你就得确保血袋的管路用生理盐水冲好，别用乳酸林格液，因为里面含钙。

If you don't have a rapid infuser, you're going to have to make sure that your blood tubing is primed with saline, not LR because LR has calcium in it.

不然管路很容易堵住。

You don't want it to clot off in the tubing.

就算用生理盐水冲过，在大量输血过程中，过个三四十分钟，管子里的血还是经常会凝固。

I will find that even with it being primed with saline during massive transfusion, a lot of times, you know, after thirty to sixty minutes or so, the blood in the tubing will clot off anyway.

所以你得提前做好准备，随时可能要换管子。

So just be prepared that you're going to have to change your tubing out.

如果你用的是普通输血管，记得要通过加温装置，保持血液温度，还得把血袋放进加压袋里，比如那种静脉输液用的加压袋。

Now, if you're using regular blood tubing, make sure that it's going through a ranger so that it's staying warm, and you're gonna have to put your blood in some kind of pressure bag, like a a line pressure bag.

不过很多创伤中心都会配备快速输注仪。

But a lot of institutions, trauma institutions, are going to have some kind of rapid infuser.

要么是Belmont设备，要么是Level One设备。

They're gonna have the Belmont machine or you're gonna have the level one machine.

它们外观上有点不一样。

They look slightly different.

贝尔蒙特机器只用一根管子，就能连接三个血袋，内部的泵会快速把血液输进去。

So the Belmont machine has like one tubing that can connect to three bags of blood, and it's the pump on the inside that's going to, you know, be pumping that blood rapidly through.

一级机的结构不太一样。

The level one's a little bit different.

它大概有两个气囊。

It kinda has, like, two bladders.

贝尔蒙特的话，一次可以挂三个血袋。

Like, the Belmont, you could probably hang three things at a time.

一级机只能挂两个。

The level one, you could only hang two.

它有两个气囊，靠挤压血袋把血挤出来。

It's got these two bladders, and the bladder squeeze those bags out.

这样能非常快地输入血液。

You can get blood in really quickly.

两分钟内就能输入一升液体，效率真的很惊人。

You can get a liter of fluid into somebody within, like, two minutes, which is pretty impressive.

而且你能在一分钟内把一袋血输进病人体内。

And you can get a bag of blood into somebody in less than a minute.

我觉得贝尔蒙特机器的流速最高能达到每分钟500毫升。

I think the Belmont goes up to, 500 mls per minute.

如果一袋血是300毫升，那大概四十五秒就能输完。

So if a bag of blood is 300, you're gonna get that in in, you know, forty five seconds or so.

不管用过多少次，每次遇到紧急情况，我还是很难快速把机器调好。

Always find that no matter how many times I use this machine, I still have a hard time setting it up when there's an emergency situation going on.

我总是让麻醉技术员待命，他们对设备特别熟悉，能很快装好，所以只要知道要用大量输血方案，我就让他们来操作。

I always make sure that I have the anesthesia tech on standby, and they're usually really knowledgeable with the equipment and how to set it up very quickly, so I'll have them set it up for me if I know that I'm gonna be using some kind of MTP.

输血的时候，总会有输血相关损伤的风险。

Now when it comes to transfusion, there's always a risk of transfusion related injuries.

最主要的两种输血并发症是TRALI和TACO。

The two major transfusion related injuries are TRALI and TACO.

听到这两个缩写大家常会笑，但一个跟肺损伤有关，另一个是心脏负担过重引起的。

People always giggle when they hear those names, but one is related to lung injury, one is related to cardiac injury or cardiac overload.

TRALI是输血相关急性肺损伤，拼写是T-R-A-L-I；TACO是输血相关循环超负荷，拼写是T-A-C-O。

So TRALI is transfusion related acute lung injury, t r a l I, and TACO is transfusion related cardiac overload, t a c o.

我们先来聊聊TRALI。

So let's talk about TRALI first.

TRALI和急性呼吸窘迫综合征非常相似。

So TRALI is very similar to ARDS.

通常发生在输血后六小时左右，TRALI的死亡率大概在百分之五到十之间。

It typically happens about six hours post transfusion, and there's actually a five to ten percent mortality rate associated with TRALI.

其实TRALI更容易发生在输注血小板的时候。

Now what happens during TRALI is that it's more likely to happen actually with platelets.

其次是新鲜冰冻血浆，然后才是浓缩红细胞。

Then the second most likely component is FFP and then PRBCs.

原因在于，血小板和新鲜冰冻血浆都是来自多个献血者的混合制品。

And the reason is because platelets and FFP, they're pulled from a lot of different donors.

所以这些制品里会含有供体的抗体，它们会攻击受血者的白细胞。

And so you have donor antibodies that are, you know, in the platelets and in the FFP that are going to basically attack the recipient's leukocytes.

这会激活补体系统，导致中性粒细胞大量涌入肺部。

And this causes this complement activation to happen and influx of neutrophils that go into the lungs.

这些细胞会释放大量细胞毒性物质，造成肺部内皮损伤和毛细血管渗漏。

And what this is going to do is release a lot of cytotoxic agents, which then cause a lot of endothelial damage and capillary leak within the lungs.

这类患者常常表现为严重低血压，并出现非心源性肺水肿。

Oftentimes, these patients present as very hypotensive, and they have this non cardiogenic pulmonary edema.

主要需要关注的抗体是HLA抗体和HNA抗体。

Now the main antibodies to look for are the HLA, the anti HLA, and the anti HNA antibodies.

如果在血液制品中检测到这两种抗体，患者发生TRALI的风险会显著升高。

So if you see those two as far as far as the blood products, then those patients are gonna be a much higher risk of developing TRALI.

HLA是人类白细胞抗原，HNA是人类中性粒细胞抗原。

Now HLA stands for human leukocyte antigens, and HNA is human neutrophil antigens.

正是针对这些抗原的抗体，增加了TRALI的发生风险。

So it's antibodies against those antigens that are going to increase the risk of TRALI.

TACO则可能发生在损伤控制性复苏的过程中。

Now TACO can occur from damage control resuscitation.

这种情况也可能在输血后六小时左右发生。

This can also occur about six hours post transfusion.

这里的情况是，输注血制品的速度超过了患者心脏的输出能力。

And, basically, what's happening here is that the blood products are administered at a faster rate than the patient's cardiac output.

最危险的情况是，出血源已经控制住了，却还在快速输注血制品。

Patients that are at the most risk of developing this is when you're still administering blood products extremely quickly after the source of the bleeding has already been controlled.

一旦患者的出血得到控制，就要减慢输血速度。

So once the patient's hemorrhage has been controlled, slow down your transfusions.

没必要再用快速输液器或者贝尔蒙特设备大量输血。

You don't need to keep giving them massive amounts of blood using the rapid infuser or using the Belmont.

可以把输血速度调低一些。

You can turn down that rate.

血制品可以慢慢输，比如用十分钟到十五分钟，而不是一分钟内完成。

You know, you still give the blood, but you can have it go in over ten, fifteen minutes rather than over one minute.

任何血制品都可能引发这种情况。

This can occur from any blood product.

TRALI 通常更常见于血小板和新鲜冰冻血浆，但任何血制品都可能引发 TACO；TACO 患者往往血压偏高、血容量过多，而 TRALI 患者则多表现为低血压。

Whereas TRALI usually occurs more likely from the platelets and the FFP, any blood product can cause TACO, and these patients are actually more hypertensive and hypervolemic versus the TRALI, which is going to be more hypotensive.

这些患者通常还会出现心脏扩大和肺水肿，我们一般会给他们用一些利尿剂。

These patients are also going to have cardiomegaly and pulmonary edema, and for these patients we usually want to administer some kind of diuretic.

TRALI 和 TACO 的另一个区别是，部分 TRALI 患者可能会发烧，但 TACO 患者几乎从不发烧。

Another difference between TRALI and TACO is that TRALI, some of those patients can actually be febrile, whereas TACO usually they're never febrile.

这是另一个需要留意的体征和症状。

So another sign and symptom to look out for.

接下来简单聊聊升压药。

Now let's talk briefly about vasopressors.

在创伤麻醉中，升压药总体上是应该避免使用的。

Vasopressors in general in trauma anesthesia are a big no no.

它们只能作为临时措施，用于在等待血制品到位时应对严重低血压。

They should only be a temporizing solution for pretty severe hypotension while you're waiting for your blood products to become available.

你已经启动了大量输血方案了。

So you've already called MTP.

已经在路上了。

It's on its way.

你的血压是40过20。

Your blood pressure is, 40 over 20.

好吧，明白了。

It's like, okay.

可以先给一点去甲肾上腺素或者苯肾上腺素，就几分钟，撑到血制品到为止。

Give a little bit of, you know, nor epi or some phenylephrine just to buy you, you know, just a couple minutes before you get those blood products in.

可以开始输注或者推注，但你的目标始终是尽快停掉这些药。

You can start infusions or give boluses, but your goal always has to be to stop it as fast as possible.

升压药、正性肌力药这类药物通常和更高的死亡率有关。

Vasopressors and inotropes and medications like that are generally associated with higher mortality rates.

唯一例外的是血管加压素。

The only vasopressor that actually isn't is vasopressin.

有一项大型研究叫AVERT研究，全称是创伤性休克早期复苏中使用精氨酸血管加压素。

So there's this big study called the AVERT study, a v e r t study, which is the arginine vasopressin during their early resuscitation of traumatic shock.

他们做了一项研究，发现对于难治性低血压的患者，在积极输血的同时，给予5到10单位的加压素推注，再持续输注每分钟0.04单位，是创伤救治中唯一相对安全的升压药。

And they did this study where if the patient has refractory hypotension, then giving vasopressin five to ten unit boluses followed by an infusion of point zero four units per minute in addition to aggressive blood product administration was pretty much the only safe vasopressor that can be given during trauma.

另一个可以提升升压药效果的措施是使用糖皮质激素，如果你不得不使用升压药的话。

Another thing to consider that can improve the responsiveness of vasopressors if you need to use them is giving steroids.

很多严重创伤的患者，肾上腺根本跟不上身体应对创伤的巨大压力，这时候补充100毫克氢化可的松，能有效改善他们的血压。

A lot of times when somebody is very traumatically injured, their adrenal glands cannot keep up with the stress of trying to respond to this traumatic injury, and so giving some kind of supplemental hydrocortisone, a hundred milligrams, can improve the blood pressure in these patients.

在控制住出血之后，我们还得继续进行复苏支持。

So after we control the hemorrhage, there's still some ongoing resuscitation that we need to do.

患者的身体还在拼命追赶状态。

The patients are still trying to catch up.

他们的组织依然缺氧。

Their tissues are still trying to get oxygen.

体内仍然处于酸中毒状态。

They're still acidotic.

所以我们得持续进行这套流程：保持体温、纠正凝血功能紊乱、调整电解质、监测乳酸水平，以及处理酸碱失衡。

So we wanna keep going in this cycle of, you know, keeping patients warm, treating their coagulopathy, treating their electrolyte abnormalities, looking at their lactate levels, and treating their acid base problems.

所以我们还得继续为患者进行复苏。

So we're gonna keep resuscitating patients.

虽然不用像在MTP期间那么急、那么猛，但我们得不断循环：查看化验结果、评估患者的血流动力学和生命体征、做体格检查、与手术团队沟通，就这样反复调整，直到患者情况好转。

We just don't need to be as fast and as aggressive as we were during the MTP, but we're going back and forth between like looking at our lab values, assessing the patient's hemodynamics and vital signs, and looking at them, doing physical assessment, communicating with the surgical team, and going around this cycle until we get patients to a better spot.

上次我们简单聊过化验指标的事。

We talked a little bit about labs last time.

这些化验结果会直接告诉我们复苏做得怎么样。

Our labs are really going to guide how well we are resuscitating our patients.

我们最关注的化验之一就是血气分析。

One of the main labs that we look at are going to be our blood gases.

我们也会关注电解质水平。

We're also gonna look at our electrolytes.

关于血气，我们的目标是纠正代谢性酸中毒，主要靠补充足够的血液和新鲜冰冻血浆来实现。

And as far as our blood gases, we want to correct their metabolic acidosis, and we're going to correct it by giving adequate blood and FFP or plasma resuscitation.

过去很多人一看到酸中毒就马上用碳酸氢钠，不过现在这种做法已经少多了。说实话，对创伤患者来说，这可能是最不靠谱的纠正酸中毒的方法。

Now a lot of people in the past, I would say people don't do this as much anymore, very quickly go to the sodium bicarbonate in order to correct acidosis, and I would say that is probably one of the worst things that you can give in order to correct acidosis, especially in trauma patients.

这就像贴个创可贴应付问题，而不是解决根本——组织缺氧，反而会让酸中毒更严重。

That's like trying to put a band aid on the problem rather than correcting the problem itself, which is that the tissue is not getting enough oxygen, and it can make your acidosis worse.

对吧？

Right?

因为用了碳酸氢盐，接着就触发了碳酸氢盐缓冲系统，那这个反应的最终结果是什么？

Because you have bicarb, and then you have the bicarbonate buffer system, and what happens at the end of that equation?

对吧？

Right?

你会产生更多二氧化碳，而二氧化碳会让你的酸中毒更厉害。

You're gonna have more c o two, and c o two is going to make you even more acidotic.

所以我们不建议用碳酸氢钠。

So we don't wanna give sodium bicarbonate.

看血气的时候，我们主要看碱剩余值。

When we're looking at our blood gases, we look at basically our base excess.

如果情况好转，碱剩余值应该接近零或者偏正。

The base excess, when you're doing well, it's going to be around zero or in the positive.

当情况不好时，碱剩余会低于负六。

When you're doing bad, it's gonna be less than negative six.

比如碱剩余是负十七，那说明病人已经明显酸中毒了。

So, you know, looking at a base excess of like negative 17, well, patient is pretty acidotic.

如果乳酸水平超过1.8，同时碱剩余又很低，我们就知道还得继续给病人补液复苏。

Looking at our lactate levels, you know, our lactate levels are above 1.8 and your base excess is really low, we know that we need to continue to resuscitate these patients.

我说过，用升压药只会让情况更糟。

Like I said, giving some kind of vasopressor is going to make things worse.

它会让微血管收缩，虽然血压数值看着正常甚至偏高，但血细胞根本到不了组织，因为微循环被堵住了。

What it's going to do is clamp down the microvasculature so that even though artificially it makes you feel good that the numbers are normal or high, the blood cells are not getting to the tissue because the microvasculature is clamped down.

这反而会增加死亡率。

It's going to actually increase mortality.

所以我们尽量避免使用升压药。

So we want stay away from our vasopressors as much as possible.

再看电解质，创伤患者常出现一些典型的电解质紊乱。

Looking at our electrolytes, so there are some pretty common electrolyte abnormalities in trauma patients.

低钙血症很常见，因为我们输了很多血制品，必须持续补钙。

Hypocalcemia, of course, we need to continue to give our calcium because we're transfusing so many products.

低钠血症也很普遍。

Hyponatremia is pretty common.

低钾血症在患者中也很常见，特别是用了某些升压药，或者pH值波动时，钾离子会在细胞内外移动。

Hypokalemia is also very common in patients, especially if you're giving, certain vasopressors and the pH shifts can cause potassium to move in and out of the cell.

有时候也会出现高钾血症，尤其是患者有严重挤压伤的时候，具体要看创伤的机制。

You can also see hyperkalemia, especially if the patient has some kind of major crush injury, just depends on the mechanism of the trauma.

患者是不是有横纹肌溶解？

So patients has rhabdomyolysis, right?

这种情况会导致高钾血症，我们也要留意这一点。

They're going to have hyperkalemia, so we want to keep that in mind as well.

如果患者在院前接受了大量液体，比如很多生理盐水，可能会出现高氯血症，从而引发代谢性酸中毒。

If the patient received a lot of fluids, especially in the prehospital area, like a lot of normal saline, they could have hyperchloremia, so metabolic acidosis related to that instead.

我们尤其要关注创伤性脑损伤的患者群体。

We especially want to keep in mind our TBI population, our traumatic brain injury population.

他们对钠水平非常敏感，必须避免钠过低，否则会加重脑部肿胀。

They're very sensitive to their sodium levels, making sure that they're not too hyponatremic, which can increase the amount of swelling that's in the brain.

以上就是关于血液制品、液体管理以及输血相关并发症的概览，还有一些需要留意的化验指标。

So that is a broad overview of blood products and fluid management and some transfusion related injuries, some lab values to keep in mind.

请继续关注，我们接下来还会继续这个系列。

Definitely stick around as we continue this series.

下一讲我们会深入细节，一步步讲清楚创伤抢救室里的操作流程，如何把病人送进手术室，怎么管理气道、建立通路，以及诱导、维持和苏醒阶段该怎么做。

The next part of the series, we're gonna talk about the nitty gritty detail about what happens exactly in the trauma bay, step by step process, and getting that patient to the OR, how to manage their airways, how to manage their lines, what to do during induction, maintenance, and emergence.

敬请持续关注，我们下一期再见。

So keep following along, we'll see you on the next episode.