張循善輸血治療傳統(tǒng)觀念的變革與更新XXXX省醫(yī)學(xué)會(huì)

輸血治療傳統(tǒng)觀念的變革與更新

安徽醫(yī)科大學(xué)第一附屬醫(yī)院張循善1主要內(nèi)容詢證輸血醫(yī)學(xué)新觀念現(xiàn)代輸血療法的臨床應(yīng)用

2詢證輸血醫(yī)學(xué)新觀念輸血作為重癥患者的支持療法沒有詢證依據(jù)同種輸血能夠?qū)е峦饪苹颊呒爸匕Y患者不良轉(zhuǎn)歸輸血不能促進(jìn)傷口愈合“失多少血，補(bǔ)多少血”是過時(shí)、錯(cuò)誤觀念3CritCareMed2009Vol.37,No.12.3124CritCareMed2004;32[Suppl.]:S542–S547意大利國(guó)家指南BloodTransfus2009;7:49-64AnnalsofInternalMedicine2012；157（1）：50輸血作為支持療法不再是現(xiàn)代紅細(xì)胞輸注指征4敗血癥患者要求較高Hb水平的適應(yīng)證

不包括支持目的

ConditionsinsepticpatientsthatmayrequireahigherhemoglobinAcuteinstabilityCardiovasculardiseaseCoronaryarterydiseaseLowcardiacoutputPulmonarydiseaseSeverearterialhypoxemiaOrganortissueischemiaSeveremixedvenousdesaturation（混合靜脈血氧飽和度，過低表明組織氧合障礙）Elevatedlactatelevel

Useofbloodproductsinsepsis:Anevidence-basedreview.CritCareMed2004;32(Suppl):S542–S547.5FFP適應(yīng)證不包括抗感染

輸注FFP不能作為支持療法

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

Useofbloodproductsinsepsis:Anevidence-basedreview.CritCareMed2004;32(Suppl):S542–S547.6重癥患者輸注紅細(xì)胞導(dǎo)致的不良轉(zhuǎn)歸From571articlesscreened,45metinclusioncriteriaIn42ofthe45studiestherisksofRBCtransfusionoutweighedthebenefits;Seventeenof18studies,demonstratedthatRBCtransfusionswereanindependentpredictorofdeath;Twenty-twostudiesexaminedtheassociationbetweenRBCtransfusionandnosocomialinfection;inallthesestudiesbloodtransfusionwasanindependentriskfactorforinfection.RBCtransfusionssimilarlyincreasedtheriskofdevelopingmulti-organdysfunctionsyndrome(threestudies)andacuterespiratorydistresssyndrome(sixstudies).

MarikPE,CorwinHL.Efficacyofredbloodcelltransfusioninthecriticallyill:asystematicreviewoftheliterature[J].CritCareMed.2008;36(9):2667-26747相對(duì)危險(xiǎn)度腹腔間隙綜合征8910Prospective,multiplecenter,observationalcohortstudy（觀測(cè)隊(duì)列列研究）of4,892ICUptsintheUSPropensityscore（傾向指數(shù)數(shù)）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研究對(duì)對(duì)象研究結(jié)結(jié)論15老年退退伍軍軍人局局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患者輸輸注紅紅細(xì)胞胞導(dǎo)致致的不不良轉(zhuǎn)轉(zhuǎn)歸機(jī)機(jī)制Storagelesion庫(kù)存紅紅細(xì)胞胞2.3-DPG含含量下下降MetabolicacidosisAlteredoxygencarryingcapacity庫(kù)存紅紅細(xì)胞胞變形形能力力下降降庫(kù)存紅紅細(xì)胞胞攜帶帶NO能力力減弱弱Increasedredcelldeathwithincreasedageofblood(~30%dead)Noimprovementinoxygenutilizationatthetissuelevel同種輸輸血的的免疫疫負(fù)向向調(diào)節(jié)節(jié)作用用202122研究結(jié)結(jié)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輸血不不能促促進(jìn)傷傷口愈愈合25手術(shù)切切口愈愈合紊紊亂診診斷標(biāo)標(biāo)準(zhǔn)結(jié)果和和機(jī)制制26underwentlaparotomy（（剖腹腹術(shù)））underwentgastrectomy（（胃切切除））underwentgastroduodenostomy（（胃十十二指指腸吻吻合術(shù)術(shù)）CONCLUSIONS:Bloodtransfusionsincreasedtheincidenceofanastomoticabscess（膿膿腫））andimpairedanastomoticwoundhealing.272001andJune2005wehaveperformedaprospectiveobservationalstudyin1553electiveandemergencypatientswhounderwentmediansternotomyforheartsurgery.CONCLUSIONS:Accordingtoourresults,thetotalamountofallogeneicbloodtransfusedisamajorfactorcontributingtosternaldehiscence（胸胸骨裂開））regardlessofotherriskpreconditions.EuropeanJournalofAnaesthesiology:May2006-Volume23-Issue-p1-228ColorectalDis.2007V9N4:362-72930“缺多少血血，補(bǔ)多少少血”與““失多少血血，補(bǔ)多少少血”是否否合理？？？31英國(guó)輸血一一般原則32RBCsshouldbeadministeredassingleunitsformostoperativeandinpatientindications(transfuseandreassessstrategy)exceptforongoingbloodlosswithhemodynamicinstability.Txdecisionsareclinicaljudgmentsthatshouldbebasedontheoverallclinicalassessmentoftheindividualpatient.Transfusiondecisionsshouldnotbebasedonlaboratoryparametersalone.Routinepremedicationisnotadvisedunlessthepatienthasahistoryofprevioustransfusionreactions.Premedicationhasnotbeenshowntoreducetheriskoftransfusionreactions.GuidelinesforBloodTransfusion:PRBCs33現(xiàn)代紅細(xì)胞胞輸注適應(yīng)應(yīng)癥和輸注注指征一、慢性性貧血貧血時(shí)機(jī)體體的反應(yīng)*慢性貧血的的輸血目的的提提高血紅蛋蛋白水平，，以保證組組織供氧。。因此應(yīng)當(dāng)當(dāng)輸注紅細(xì)細(xì)胞即可，，不應(yīng)輸注注全血。慢性貧血的的輸血原則則臨臨床上輸輸注紅細(xì)胞胞主要是消消除或減輕輕缺氧癥狀狀，只要將將Hb水平平提高到能能保證足夠夠的組織供供氧即可，，不需要通通過輸血將將患者的Hb水平恢恢復(fù)到正常常水平。..\紅細(xì)細(xì)胞保存\輸血到HB正常水水平不能改改變患者的的轉(zhuǎn)歸.PDF34人類耐受低低Hb的能能力35英國(guó)紅細(xì)胞胞輸注指南南

（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輸紅細(xì)胞胞指征一一般般認(rèn)為Hb降低低到正常常值的50％以下下，才需需要輸注注紅細(xì)胞胞；Hb降低不不到上述述水平但但是患者者伴有心心、肺功功能受損損或心、、腦等重重要臟器器的血管管硬化，，使組織織得不到到足夠的的氧時(shí)，，也需要要輸注紅紅細(xì)胞。。貧血病因因的確定定和治療療40二、急性性貧血由于手術(shù)術(shù)、創(chuàng)傷傷和其它它疾病引引起的急急性貧血血，臨床床醫(yī)生在在輸血指指征掌握握、血液液成分品品種的選選擇、輸輸注劑量量的確定定時(shí)，應(yīng)應(yīng)當(dāng)根據(jù)據(jù)患者的的臨床具具體情況況，才能能做出正正確的決決定，才才能安全全、有效效、及時(shí)時(shí)的進(jìn)行行輸血治治療。值值得注意意的是臨臨床醫(yī)生生應(yīng)當(dāng)嚴(yán)嚴(yán)格掌握握輸血指指征，減少不必要的的輸血。41臨床醫(yī)生對(duì)急急性失血的輸輸血指征把握握仍然存在問問題英國(guó)2007~2008年國(guó)家輸血血審核發(fā)現(xiàn)，，38%患者者缺少夜間輸輸血臨床指征征；消化道出出血患者輸血血澳大利亞學(xué)者者發(fā)現(xiàn)某教學(xué)學(xué)醫(yī)院bloodproductusewasinappropriatefor16%ofredcell,13%ofplateletand31%offreshfrozenplasma(FFP)transfusionepisodes.國(guó)外學(xué)者研究究結(jié)腸、直腸腸癌圍手術(shù)期期輸血存在輸輸血指征掌握握不嚴(yán)現(xiàn)象。。國(guó)內(nèi)部分外科科醫(yī)生輸血指指征掌握仍然然不嚴(yán)美國(guó)的臨床輸輸血管理42急性貧血輸血血和血液成分分選擇的依據(jù)據(jù)失血量臨床情況43失血量與輸血血指征關(guān)系患者丟失20％（新生兒兒10%）的的血容量以下下，或成人失失血量在1000毫升以以內(nèi)，不必輸輸注紅細(xì)胞；；失血量在20％～25％％時(shí)，及時(shí)補(bǔ)補(bǔ)液和輸注紅紅細(xì)胞2單位位即可；失血量在>25％時(shí)，除除了及時(shí)補(bǔ)液液和輸注紅細(xì)細(xì)胞外，可根根據(jù)患者具體體情況加輸全全血、FFP或血小板。。44英國(guó)紅細(xì)胞輸輸注指南（（2002年年）45臨床情況心肺功能受損損或伴有心腦腦血管病變的的患者，由于于心肺功能狀狀況可直接影影響機(jī)體耐受受和代償因急急性失血引起起的組織供氧氧不足，因此此應(yīng)當(dāng)適當(dāng)放放寬輸血指征征；患者失血前有有無貧血及貧貧血程度：患者骨髓和肝肝臟功能狀況況等也是在急急性出血后是是否輸血，選選擇血液制品品種類及輸血血?jiǎng)┝康闹匾蛩亍?6血小板輸注血小板輸注原原則預(yù)防性血小板板輸注治療性血小板板輸注外科患者的血血小板輸注血小板輸注后后的療效評(píng)價(jià)價(jià)47血小板輸注原原則血小板輸血療療法主要應(yīng)用用在防止患者者出血或治療療活動(dòng)性出血血。在臨床上上決定是否需需要輸注血小小板以及輸注注劑量主要取取決于患者臨臨床情況、血血小板減少的的原因、血小小板計(jì)數(shù)、患患者血小板的的功能。48預(yù)防性血小板板輸注的有關(guān)關(guān)問題血小板輸注劑劑量一般預(yù)防性血血小板輸注劑劑量為每10Kg體重輸輸注2單位血血小板/d或或1個(gè)治療量量的機(jī)采血小小板。目前尚尚無證據(jù)表明明此類患者需需要輸注更大大劑量的血小小板。計(jì)算公式＝預(yù)計(jì)達(dá)到的Plt（mm3）－患者原有有的Plt（（mm3）×1.4×25000注：國(guó)外每單單位血小板是是由400ml全血中制制備，國(guó)內(nèi)是是從200ml全血中制制備；國(guó)外血血小板每單位位是70×109；國(guó)內(nèi)24××109。49預(yù)防性血小板板輸注的有關(guān)關(guān)問題血小板輸注指指征Plt<5~10×109/L；長(zhǎng)期輸注血小小板者難以達(dá)到療效效時(shí)，應(yīng)當(dāng)應(yīng)應(yīng)用CCI來來判斷血小板板的輸注效果果；患者血小板功功能異常例如服用阿司司匹林和尿毒毒癥，臨床醫(yī)醫(yī)生應(yīng)當(dāng)根據(jù)據(jù)臨床具體情情況決定是否否需要輸注血血小板，不要要機(jī)械的根據(jù)據(jù)PLT；ITP患者血血小板輸注問問題50輸注血小板治治療活動(dòng)性出出血患者PLT<50×109/L并伴有活活動(dòng)性出血時(shí)時(shí)，應(yīng)當(dāng)進(jìn)行行血小板輸注注。51外科血小板輸輸注較大的外科手手術(shù)患者術(shù)前前PLT最好好維持在50×109/L以上。血小板減少的的患者術(shù)后應(yīng)應(yīng)當(dāng)維持PLT>50××109/L，以利于于損傷愈合及及防止出血。。52血小板輸注注的療效評(píng)評(píng)估對(duì)長(zhǎng)期反復(fù)復(fù)輸注血小小板者應(yīng)當(dāng)當(dāng)進(jìn)行血小小板療效評(píng)評(píng)估，確定定下次血小小板輸注時(shí)時(shí)間和劑量量。53血小板糾正正指數(shù)correctedcountincrement（CCI）（輸注后血血小板計(jì)數(shù)數(shù)－輸注前前血小板計(jì)計(jì)數(shù)）×體體表面積(m2)血小板糾正正指數(shù)（CCI）＝＝輸注的血小小板總數(shù)(1011)血小板計(jì)數(shù)數(shù)單位是109/L，輸注注后血小板板計(jì)數(shù)為輸注后1小時(shí)Plt。CCI<7～10表表示血小板板輸注無效效54FFP的輸輸注問題不應(yīng)做為營(yíng)營(yíng)養(yǎng)劑、擴(kuò)擴(kuò)容劑嚴(yán)格掌握適適應(yīng)征*輸注劑量10～15ml/kg,可可提高凝血血因子到正正常水平的的25％足量55FFP輸注注適應(yīng)癥1.TTP;2.大量量輸血或術(shù)術(shù)間急性出出血，疑凝凝血因子缺缺乏；3.華法法林過量的的及時(shí)糾正正（出血或或即將手術(shù)術(shù)）；4.PT/APTT>1.5對(duì)照，，伴急性出出血或侵入入性手術(shù)前前出現(xiàn)下列列情況：※單個(gè)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