张循善输血治疗传统观念的变革与更新XXXX省医学会

输血治疗传统观念的变革与更新

安徽医科大学第一附属医院张循善1主要内容询证输血医学新观念现代输血疗法的临床应用

2询证输血医学新观念输血作为重症患者的支持疗法没有询证依据同种输血能够导致外科患者及重症患者不良转归输血不能促进伤口愈合“失多少血，补多少血”是过时、错误观念3CritCareMed2009Vol.37,No.12.3124CritCareMed2004;32[Suppl.]:S542–S547意大利国家指南BloodTransfus2009;7:49-64AnnalsofInternalMedicine2012；157（1）：50输血作为支持疗法不再是现代红细胞输注指征4败血症患者要求较高Hb水平的适应证

不包括支持目的

ConditionsinsepticpatientsthatmayrequireahigherhemoglobinAcuteinstabilityCardiovasculardiseaseCoronaryarterydiseaseLowcardiacoutputPulmonarydiseaseSeverearterialhypoxemiaOrganortissueischemiaSeveremixedvenousdesaturation（混合静脉血氧饱和度，过低表明组织氧合障碍）Elevatedlactatelevel

Useofbloodproductsinsepsis:Anevidence-basedreview.CritCareMed2004;32(Suppl):S542–S547.5FFP适应证不包括抗感染

输注FFP不能作为支持疗法

Fresh-FrozenPlasmaTransfusionQuestion:WhenshouldFFPbetransfusedinpatientswithseveresepsis?Recommendation:RoutineuseofFFPtocorrectlaboratoryclottingabnormalitiesintheabsenceofbleedingorplannedinvasiveproceduresisnotrecommended.FFPisindicatedforcoagulopathyduetodocumenteddeficiencyofcoagulationfactors(increasedPTAPTT)inthepresenceofactivebleedingorbeforesurgicalorinvasiveprocedures.

Useofbloodproductsinsepsis:Anevidence-basedreview.CritCareMed2004;32(Suppl):S542–S547.6重症患者输注红细胞导致的不良转归From571articlesscreened,45metinclusioncriteriaIn42ofthe45studiestherisksofRBCtransfusionoutweighedthebenefits;Seventeenof18studies,demonstratedthatRBCtransfusionswereanindependentpredictorofdeath;Twenty-twostudiesexaminedtheassociationbetweenRBCtransfusionandnosocomialinfection;inallthesestudiesbloodtransfusionwasanindependentriskfactorforinfection.RBCtransfusionssimilarlyincreasedtheriskofdevelopingmulti-organdysfunctionsyndrome(threestudies)andacuterespiratorydistresssyndrome(sixstudies).

MarikPE,CorwinHL.Efficacyofredbloodcelltransfusioninthecriticallyill:asystematicreviewoftheliterature[J].CritCareMed.2008;36(9):2667-26747相对危险度腹腔间隙综合征8910Prospective,multiplecenter,observationalcohortstudy（观测队列列研究）of4,892ICUptsintheUSPropensityscore（倾向指数数）matchedDesignedtoexaminetherelationshipofanemiaandRBCtransfusionwithclinicaloutcomesAlmost95%ofpatientsadmittedtotheICUhaveaHblevelbelow“normal”byday3Intotal,11,391RBCunitsweretransfused.Overall,44%ofptsadmittedtotheICUreceivedoneormoreRBCunitswhileintheICUCritCareMed.2004Jan;32(1):39-5211Themeanpre-transfusionHbwas8.6±±1.7g/dLRBCtransfusionwasindependentlyassociatedwithhighermortality(OR1.65CI1.35-2.03).OR2.62if3-4unitstransfusedp<0.000135%ofBloodtransfusedinpatientswithHgb9CritCareMed.2004Jan;32(1):39-5212Analysisof24,112enrolleesin3largeinternationaltrialsofpatientswithacutecoronarysyndromesAssociationbetweentransfusionandoutcomeCoxproportionalhazardsmodelingMainoutcome=30daymortalityRaoSVetal.JAMA.2004;292:1555-156213BloodTransfusionandClinicalOutcomeinAcuteCoronarySyndromeRaoSVetal.JAMA.2004;292:1555-1562TransfusionNoTransfusionAdjustedhazardratio3.94(3.26-4.75)14研究对对象研究结结论15老年退退伍军军人局局161715,592CardiovascularoperationsInfectionendpointsbacteremia,SSI55%ofptsreceivedPRBCs,21%plts,13%FFP,3%cryoprecipitateIncreasedRBCtxassociatedwithincreasedinfection(p<0.0001),confirmedbylogisticregressionanalysis.JAmCollSurg2006;202:131-13818EffectofBloodTransfusiononLong-TermSurvivalAfterCardiacOperation1915CABGptsAftercorrectionforcomorbiditiesandotherfactors,txwasstillassociatedwitha70%increaseinmortality(RR1.7;95%CI1.4to2.0;p0.001).EngorenMCetal.(MCO,Toledo)AnnThoracSurg2002;74:1180––619患者输输注红红细胞胞导致致的不不良转转归机机制Storagelesion库存红红细胞胞2.3-DPG含含量下下降MetabolicacidosisAlteredoxygencarryingcapacity库存红红细胞胞变形形能力力下降降库存红红细胞胞携带带NO能力力减弱弱Increasedredcelldeathwithincreasedageofblood(~30%dead)Noimprovementinoxygenutilizationatthetissuelevel同种输输血的的免疫疫负向向调节节作用用202122研究结结果Themediandurationofstoragewas11daysfornewerbloodand20daysforolderblood.Patientswhoweregivenolderunitshadhigherratesofin-hospitalmortality(2.8%vs.1.7%,P=0.004),intubationbeyond72hours(9.7%vs.5.6%,P<0.001),renalfailure(2.7%vs.1.6%,P=0.003),andsepsisorsepticemia(4.0%vs.2.8%,P=0.01).Acompositeofcomplicationswasmorecommoninpatientsgivenolderblood(25.9%vs.22.4%,P=0.001).Similarly,olderbloodwasassociatedwithanincreaseintherisk-adjustedrateofthecompositeoutcome(P=0.03).At1year,mortalitywassignificantlylessinpatientsgivennewerblood(7.4%vs.11.0%,P<0.001).23ImmuneEffectsofBloodImmunologiceffectsofallogenicbloodTxDecreasedT-cellproliferationDecreasedCD3,CD4,CD8T-cellsIncreasedsolublecytokinereceptorsTNF-R,sIL-2RIncreasedsuppressorT-cellactivityReducednaturalkillercellactivityMcAlisterFAetal,BrJSurg1998;85:171-8.InnerhoferPetal,Transfusion1999;39:1089-96.24输血不不能促促进伤伤口愈愈合25手术切切口愈愈合紊紊乱诊诊断标标准结果和和机制制26underwentlaparotomy（（剖腹腹术））underwentgastrectomy（（胃切切除））underwentgastroduodenostomy（（胃十十二指指肠吻吻合术术）CONCLUSIONS:Bloodtransfusionsincreasedtheincidenceofanastomoticabscess（脓脓肿））andimpairedanastomoticwoundhealing.272001andJune2005wehaveperformedaprospectiveobservationalstudyin1553electiveandemergencypatientswhounderwentmediansternotomyforheartsurgery.CONCLUSIONS:Accordingtoourresults,thetotalamountofallogeneicbloodtransfusedisamajorfactorcontributingtosternaldehiscence（胸胸骨裂开））regardlessofotherriskpreconditions.EuropeanJournalofAnaesthesiology:May2006-Volume23-Issue-p1-228ColorectalDis.2007V9N4:362-72930“缺多少血血，补多少少血”与““失多少血血，补多少少血”是否否合理？？？31英国输血一一般原则32RBCsshouldbeadministeredassingleunitsformostoperativeandinpatientindications(transfuseandreassessstrategy)exceptforongoingbloodlosswithhemodynamicinstability.Txdecisionsareclinicaljudgmentsthatshouldbebasedontheoverallclinicalassessmentoftheindividualpatient.Transfusiondecisionsshouldnotbebasedonlaboratoryparametersalone.Routinepremedicationisnotadvisedunlessthepatienthasahistoryofprevioustransfusionreactions.Premedicationhasnotbeenshowntoreducetheriskoftransfusionreactions.GuidelinesforBloodTransfusion:PRBCs33现代红细胞胞输注适应应症和输注注指征一、慢性性贫血贫血时机体体的反应*慢性贫血的的输血目的的提提高血红蛋蛋白水平，，以保证组组织供氧。。因此应当当输注红细细胞即可，，不应输注注全血。慢性贫血的的输血原则则临临床上输输注红细胞胞主要是消消除或减轻轻缺氧症状状，只要将将Hb水平平提高到能能保证足够够的组织供供氧即可，，不需要通通过输血将将患者的Hb水平恢恢复到正常常水平。..\红细细胞保存\输血到HB正常水水平不能改改变患者的的转归.PDF34人类耐受低低Hb的能能力35英国红细胞胞输注指南南

（2002年））36RedBloodCellTransfusion:AClinicalPracticeGuideline

FromtheAABBAnnInternMed.2012V157N1:49-58直立3738MethodsWeenrolled838criticallyillpatientswhohadhemglobinconcentrationsoflessthan9.0g/dlandrandomlyassigned418patientstoarestrictivestrategyoftransfusion,inwhichredcellsweretransfusedifthehemoglobinconcentrationdroppedbelow7.0g/dlandhemoglobinconcentrationsweremaintainedat7.0to9.0g/dl,and420patientstoaliberalstrategy,inwhichtransfusionsweregivenwhenthehemoglobinconcentrationfellbelow10.0g/dlandhemoglobinconcentrationsweremaintainedat10.0to12.0g/dl.ResultsOverall,30-daymortalitywassimilarinthetwogroups(18.7percentvs.23.3percent,P=0.11).Themortalityrateduringhospitalizationwassignificantlylowerintherestrictive-strategygroup(22.2percentvs.28.1percent,P=0.05).39输红细胞胞指征一一般般认为Hb降低低到正常常值的50％以下下，才需需要输注注红细胞胞；Hb降低不不到上述述水平但但是患者者伴有心心、肺功功能受损损或心、、脑等重重要脏器器的血管管硬化，，使组织织得不到到足够的的氧时，，也需要要输注红红细胞。。贫血病因因的确定定和治疗疗40二、急性性贫血由于手术术、创伤伤和其它它疾病引引起的急急性贫血血，临床床医生在在输血指指征掌握握、血液液成分品品种的选选择、输输注剂量量的确定定时，应应当根据据患者的的临床具具体情况况，才能能做出正正确的决决定，才才能安全全、有效效、及时时的进行行输血治治疗。值值得注意意的是临临床医生生应当严严格掌握握输血指指征，减少不必要的的输血。41临床医生对急急性失血的输输血指征把握握仍然存在问问题英国2007~2008年国家输血血审核发现，，38%患者者缺少夜间输输血临床指征征；消化道出出血患者输血血澳大利亚学者者发现某教学学医院bloodproductusewasinappropriatefor16%ofredcell,13%ofplateletand31%offreshfrozenplasma(FFP)transfusionepisodes.国外学者研究究结肠、直肠肠癌围手术期期输血存在输输血指征掌握握不严现象。。国内部分外科科医生输血指指征掌握仍然然不严美国的临床输输血管理42急性贫血输血血和血液成分分选择的依据据失血量临床情况43失血量与输血血指征关系患者丢失20％（新生儿儿10%）的的血容量以下下，或成人失失血量在1000毫升以以内，不必输输注红细胞；；失血量在20％～25％％时，及时补补液和输注红红细胞2单位位即可；失血量在>25％时，除除了及时补液液和输注红细细胞外，可根根据患者具体体情况加输全全血、FFP或血小板。。44英国红细胞输输注指南（（2002年年）45临床情况心肺功能受损损或伴有心脑脑血管病变的的患者，由于于心肺功能状状况可直接影影响机体耐受受和代偿因急急性失血引起起的组织供氧氧不足，因此此应当适当放放宽输血指征征；患者失血前有有无贫血及贫贫血程度：患者骨髓和肝肝脏功能状况况等也是在急急性出血后是是否输血，选选择血液制品品种类及输血血剂量的重要要因素。46血小板输注血小板输注原原则预防性血小板板输注治疗性血小板板输注外科患者的血血小板输注血小板输注后后的疗效评价价47血小板输注原原则血小板输血疗疗法主要应用用在防止患者者出血或治疗疗活动性出血血。在临床上上决定是否需需要输注血小小板以及输注注剂量主要取取决于患者临临床情况、血血小板减少的的原因、血小小板计数、患患者血小板的的功能。48预防性血小板板输注的有关关问题血小板输注剂剂量一般预防性血血小板输注剂剂量为每10Kg体重输输注2单位血血小板/d或或1个治疗量量的机采血小小板。目前尚尚无证据表明明此类患者需需要输注更大大剂量的血小小板。计算公式＝预计达到的Plt（mm3）－患者原有有的Plt（（mm3）×1.4×25000注：国外每单单位血小板是是由400ml全血中制制备，国内是是从200ml全血中制制备；国外血血小板每单位位是70×109；国内24××109。49预防性血小板板输注的有关关问题血小板输注指指征Plt<5~10×109/L；长期输注血小小板者难以达到疗效效时，应当应应用CCI来来判断血小板板的输注效果果；患者血小板功功能异常例如服用阿司司匹林和尿毒毒症，临床医医生应当根据据临床具体情情况决定是否否需要输注血血小板，不要要机械的根据据PLT；ITP患者血血小板输注问问题50输注血小板治治疗活动性出出血患者PLT<50×109/L并伴有活活动性出血时时，应当进行行血小板输注注。51外科血小板输输注较大的外科手手术患者术前前PLT最好好维持在50×109/L以上。血小板减少的的患者术后应应当维持PLT>50××109/L，以利于于损伤愈合及及防止出血。。52血小板输注注的疗效评评估对长期反复复输注血小小板者应当当进行血小小板疗效评评估，确定定下次血小小板输注时时间和剂量量。53血小板纠正正指数correctedcountincrement（CCI）（输注后血血小板计数数－输注前前血小板计计数）×体体表面积(m2)血小板纠正正指数（CCI）＝＝输注的血小小板总数(1011)血小板计数数单位是109/L，输注注后血小板板计数为输注后1小时Plt。CCI<7～10表表示血小板板输注无效效54FFP的输输注问题不应做为营营养剂、扩扩容剂严格掌握适适应征*输注剂量10～15ml/kg,可可提高凝血血因子到正正常水平的的25％足量55FFP输注注适应症1.TTP;2.大量量输血或术术间急性出出血，疑凝凝血因子缺缺乏；3.华法法林过量的的及时纠正正（出血或或即将手术术）；4.PT/APTT>1.5对照，，伴急性出出血或侵入入性手术前前出现下列列情况：※单个凝凝血因子缺缺乏（不包包括血友病病A/B））；※DIC;※肝衰竭竭。56Guidelinesfortheuseoffresh-frozenplasmaBritishJournalofHaematology2004;126:11Singleinheritedclottingfactordeficienciesforwhichnovirus-safefractionatedproductisavailable.[ex.FactorV]Multi-factordeficienciesassociatedwithseverebleeding(ex.DICwithbleeding)Fresh-frozenplasmaisnotindicatedinDICwithnoevidenceofbleeding.Hypofibrinogenemia:Cryoprecipitatemaybeindicatediftheplasmafibrinogenislessthan1g/l,TTP:Singlevolumedailyplasmaexchangeshouldideallybebegunatpresentation(grade

Arecommendation,level

Ibevidence)57GuidelinesforFFPSurgicalbleeding:ShouldbeguidedbytimelytestsofcoagulationFFPshouldneverbeusedasasimplevolumerelacementinadultsorchildren(gradeBrecommendation,levelIIbevidence).Massivetransfusion:Ifbleedingcontinuesafterlargevolumesofcrystalloid,redcellsandplateletshavebeentransfused,FFPandcryoprecipitatemaybegivensothatthePTandAPTTratiosareshortenedtowithin1.5,andafibrinogenconcentrationofat