合理使用血液和血液成分

合理使用血液和血液成分第1頁/共122頁合理使用血液和血液成分PaulM.Ness,M.D.醫(yī)學(xué)博士約翰霍普金斯醫(yī)學(xué)中心輸血科主任美國-馬里蘭州-巴爾的摩第2頁/共122頁MAJORPATIENTCONCERNSHowsafearebloodtransfusionswithrespecttoAIDSandothercomplications?ArethereanyalternativesthatIcanusetoavoidbloodtransfusions?第3頁/共122頁患者關(guān)注的主要內(nèi)容鑒于艾滋病和其他并發(fā)癥，輸血的安全性如何？是否有避免輸血的替代治療？第4頁/共122頁INFECTIOUSRISKSOFTRANSFUSIONAGENTPre-NATPost-NATHCV1:103,000<1:334,043HBV<1:63,000NAHTLV1:641,000NAHIV1:676,000<1:1,100,000第5頁/共122頁輸血的感染性風(fēng)險(xiǎn)病種核酸檢測前核酸檢測后HCV1:103,000<1:334,043HBV<1:63,000NA（無數(shù)據(jù)）HTLV1:641,000NA（無數(shù)據(jù)）HIV1:676,000<1:1,100,000第6頁/共122頁P(yáng)ERIOPERATIVEREDCELLTRANSFUSION

NIHCONFERENCE,1988Transfusiontriggerof10g/dlisNOTjustified;7g/dlmaybemoreappropriate.Moderateperioperativeanemiadoesnotcontributetomorbidityordelaywoundhealing.Homologoustransfusionshouldbeminimized.Alternativestohomologoustransfusionshouldbeencouraged.第7頁/共122頁圍手術(shù)期紅細(xì)胞輸血

美國國立衛(wèi)生研究院大會(huì)，1988年血紅蛋白10克/分升的輸血指針還不充分，7克/分升可能更為恰當(dāng)圍手術(shù)期輕度貧血不會(huì)導(dǎo)致發(fā)病或延遲愈合同種異體輸血應(yīng)減少到最低限度應(yīng)鼓勵(lì)替代同種異體輸血的方法第8頁/共122頁TRANSFUSIONALTERNATIVESPredepositautologoustransfusionHemodilutionIntraoperativeautologoustransfusionPharmacologictherapiesBloodsubstitutesApheresistoreducedonorexposurePathogeninactivation第9頁/共122頁輸血的替代方法預(yù)存的自體血輸注血液稀釋術(shù)中的自體血輸注藥物治療血液代用品減少獻(xiàn)血者暴露的機(jī)采病原體滅活第10頁/共122頁BLOODCOMPONENTS第11頁/共122頁血液成分全血紅細(xì)胞富血小板血漿血小板新鮮冰凍血漿血漿（成份分離）凝血因子冷沉淀第12頁/共122頁P(yáng)REFERENTIALUSEOFCOMPONENTSAvoidscirculatoryoverloadLimitsharmfulmetabolicmaterialsConcentratesrequiredmaterialforeffectivelevelsMinimizesriskofdiseasetransmissionMaximizesuseofdonatedblood第13頁/共122頁使用成分血的優(yōu)點(diǎn)避免循環(huán)超負(fù)荷降低有害代謝物質(zhì)濃縮所需的成分至有效的水平減少傳染性疾病的危險(xiǎn)最大限度地利用捐獻(xiàn)的血液第14頁/共122頁REDCELLCOMPONENTSRedbloodcellsLeukocyte-depletedRBCWashedredcellsFrozenredcellsReducevolumeRemoveleukocytesRemoveplasmaIncreasestorageperiod第15頁/共122頁紅細(xì)胞成分紅細(xì)胞去白紅細(xì)胞洗滌紅細(xì)胞冰凍紅細(xì)胞

減少容量去除白細(xì)胞去除血漿增加貯藏期第16頁/共122頁REDCELLCOMPONENTSCOMPONENTFEATURESINDICATIONSWholeBloodHighvolume;GoodflowMajorbleeding;ExchangeTxRBCConcentratesHigherHct;LowervolumeRBCDeficit;ChronicanemiaLeukodepletion<10exp6WBCReduceWBCeffectsWashedRBCRemoveplasmaAllergicreactionFrozenRBCLong-termstorageRareunits;Auto.blood第17頁/共122頁紅細(xì)胞成分成分特性適應(yīng)癥全血高容量，流動(dòng)性好大出血;換血療法濃縮紅細(xì)胞高紅細(xì)胞壓積，低容量紅細(xì)胞減少;慢性貧血去白紅細(xì)胞<106白細(xì)胞減少白細(xì)胞效應(yīng)洗滌紅細(xì)胞去除血漿過敏性反應(yīng)冰凍紅細(xì)胞長期貯存稀有血型;自體儲(chǔ)血第18頁/共122頁LEUKOCYTEDEPLETION

POTENTIALCLINICALADVANTAGESReducetransfusionreactionsfromWBCorcytokinesReduceriskofalloimmunizationReduceriskofinfectionsfromcellassociatedviruses(CMV)Reducerisksofimmunomodulation(cancerrecurrence,perioperativeinfections)第19頁/共122頁白細(xì)胞去除的潛在臨床優(yōu)勢減少白細(xì)胞或細(xì)胞因子引起的輸血反應(yīng)降低同種異體免疫反應(yīng)的風(fēng)險(xiǎn)降低感染細(xì)胞相關(guān)病毒(巨細(xì)胞病毒)的風(fēng)險(xiǎn)降低免疫調(diào)節(jié)的風(fēng)險(xiǎn)（癌癥復(fù)發(fā)，圍手術(shù)期感染）第20頁/共122頁Leukoreductiondecreases

mortalityincardiacsurgeryDeathratereducedfrom7.8%to3.5%(vandeWatering1998),and10.1%to5.5%(Bilgin2001)inrandomizedtrialsofleukoreducedtransfusionsPost-operativeinfectionhasamortalityof8-15%andistheleadingcauseofmultiorganfailuresyndromesNBlumbergMD&JMHealMRCP第21頁/共122頁減少白細(xì)胞

降低心臟外科手術(shù)的死亡率在輸注少白細(xì)胞血液的隨機(jī)試驗(yàn)中，死亡率從7.8％降到3.5％（vandeWatering1998年），從10.1％降到5.5％（Bilgin2001）手術(shù)后感染的死亡率為8-15％，是導(dǎo)致多臟器衰竭綜合癥的主要原因第22頁/共122頁Numbertotreattosaveonelife

（NTN）NucleicAcidTesting(NAT)forHIV/HCV500,000to1,000,000Costperlifesaved=$2.5-5,000,000Leukoreductionofallogeneictransfusionsincardiacsurgery20Costperlifesaved=$400-600 第23頁/共122頁(NNT)救治一人所需要的費(fèi)用艾滋病毒/丙型肝炎病毒的核酸檢測（NAT）500,000到1,000,000每個(gè)人的救治費(fèi)用$2.5-5,000,000心臟手術(shù)所用的減少白細(xì)胞的同種異體輸血20每個(gè)人的救治費(fèi)用$400-600

第24頁/共122頁TRANSFUSIONTRIGGER

RedBloodCellsCardiacoutputincreaseswithanemia,whenhemoglobinfallsbelow7grams/dlOxygenextractionincreaseswithanemiaLacticacidosisindicatesfailureofoxygendelivery;notusefulastransfusiontriggerNormalanimalsdevelopcardiacfailureatHctof10%;animalswithcoronarystenosis haveheartfailureathigherHct(17%)第25頁/共122頁紅細(xì)胞的輸血指針血紅蛋白低于7克/分升時(shí)，導(dǎo)致心輸出量增加和貧血氧攝取增加和貧血乳酸性酸中毒表明氧輸送障礙;不能作為輸血的指針正常動(dòng)物的紅細(xì)胞壓積在10％時(shí)發(fā)生心力衰竭;伴冠狀動(dòng)脈狹窄的動(dòng)物在較高紅細(xì)胞壓積（17％）時(shí)發(fā)生心力衰竭第26頁/共122頁IsAnemiaHarmfulintheICU?Hebertetal(NEJM1999)comparedaliberaltransfusionstrategytoaconservativeregimen838patientsrandomizedtotransfusedhemoglobinlevelsof7-9g/dlor10-12g/dlMorbidityandmortalitywaslowerinpatientswithconservativeregimenunlesspatientshadunstableanginaorMI.第27頁/共122頁貧血在重癥監(jiān)護(hù)病房是有害的嗎？1999年Hebert等人在新英格蘭醫(yī)學(xué)雜志上將自由輸血的策略與保守的治療方案進(jìn)行了比較。838例輸血患者按血紅蛋白7-9克/分升或10-12克/分升的水平隨機(jī)分組除了不穩(wěn)定型心絞痛或急性心肌梗死的患者，保守療法患者的發(fā)病率和死亡率較低。第28頁/共122頁RBCtransfusion“trigger”Hebert,1999Primaryoutcome:30daymortalityfromallcauses18.723.3%第29頁/共122頁紅細(xì)胞輸血“指針”主要結(jié)果：所有輸血原因的30天死亡率分析18.723.3%自由輸血策略限制輸血策略第30頁/共122頁IntraoperativeRedCellTransfusion

AnesthesiologistTaskForce,1996Transfusionisrarelyindicatedwhenhgb>10andisalmostalwaysindicatedwhenhgb<6,especiallywithacuteanemiaTransfusionsforhemoglobin6-10g/dLshouldbebaseduponriskofcomplicationsofinadequateoxygenation.SinglehemoglobintriggerforallpatientsisnotrecommendedUseofautologousoptionsormeasurestoreducebloodlossmaybebeneficalTriggerforautologousbloodmaybemoreliberalthanforallogeneicredcellsbecauseoflowerrisks第31頁/共122頁術(shù)中紅細(xì)胞輸血，麻醉師工作組，1996年當(dāng)血紅蛋白>10，很少需要輸血；當(dāng)血紅蛋白<6，特別是伴急性貧血時(shí)，幾乎都需要輸血。血紅蛋白6-10克/升的輸血應(yīng)考慮缺氧并發(fā)癥的風(fēng)險(xiǎn)。適用于所有患者的單一血紅蛋白指針尚未提出使用自體輸血或減少失血的措施是有益的因?yàn)榈惋L(fēng)險(xiǎn)，自體輸血的指針比輸注異體紅細(xì)胞更自由。第32頁/共122頁InadequateTxTherapyinWAIHA

(ExtractedfromPlaintiffLawSuits)CASEAge/SexHgLevelsTx/PregHospitalDaysComplaint121F6>301Confusion248F4.5>3.4+1SOB347M5.0>3.203SOB445M6.1>2.905SOB、Confusion545M5.9>2.701SOB第33頁/共122頁溫抗體型自身免疫性溶血性貧血中不充分的輸血治療（摘自原告訴訟）病例年齡、性別血紅蛋白水平輸血/妊娠

住院天數(shù)控告121歲/女6>301混亂248歲/女4.5>3.4+1參見醫(yī)囑單347歲/男5.0>3.203參見醫(yī)囑單445歲/男6.1>2.905參見醫(yī)囑單混亂545歲/男5.9>2.701參見醫(yī)囑單第34頁/共122頁TRANSFUSIONTRIGGER

ChronicAnemiaCardiacoutputincreaseswithanemia,whenhemoglobinfallsbelow7grams/dlOxygenextractionincreaseswithanemiaLacticacidosisindicatesfailureofoxygendelivery;notusefulastransfusiontriggerNormalanimalsdevelopcardiacfailureat10%Hct;animalswithcoronarystenosishaveheartfailureathigherHct(17%)第35頁/共122頁輸血指針：慢性貧血血紅蛋白低于7克/分升時(shí)，導(dǎo)致心輸出量增加和貧血導(dǎo)致氧攝取增加和貧血乳酸性酸中毒表明氧輸送障礙;不能作為輸血的指針正常動(dòng)物紅細(xì)胞壓積在10％時(shí)發(fā)生心力衰竭;伴冠狀動(dòng)脈狹窄的動(dòng)物在較高紅細(xì)胞壓積（17％）時(shí)發(fā)生心力衰竭第36頁/共122頁TransfusionTrigger

SevereWarmAIHAMaintainhemoglobinabove4g/dLinyoungerpatients,whooftentoleratesevereanemiaifithasdevelopedslowlyForolderpatientsorpatientswithknowncardiovasculardisease,maintainhemoglobinabove6g/dL第37頁/共122頁輸血指針

重度溫抗體型自身免疫性溶血性貧血如果是較年輕的患者，由于貧血發(fā)展緩慢，患者已耐受嚴(yán)重貧血，則應(yīng)維持其血紅蛋白在4克/分升以上。對于年老或有心血管疾病患者，維持血紅蛋白在6克/分升以上。第38頁/共122頁REDCELLINDICATIONSTreatmentofanemiaincasestooseveretobetreatedbynutritionalreplacementorironSurgicalbloodlossgreaterthan10-15%ofestimatedbloodvolumeCorrectionofperioperativeanemiatoahematocritofapproximately25%Hypotensionassociatedwithbleeding第39頁/共122頁紅細(xì)胞的適應(yīng)癥如果經(jīng)營養(yǎng)支持或補(bǔ)鐵治療貧血仍嚴(yán)重，應(yīng)輸紅細(xì)胞糾正貧血。手術(shù)失血量大于總血量的10-15％糾正圍手術(shù)期貧血使紅細(xì)胞壓積至25％低血壓伴出血第40頁/共122頁P(yáng)lateletComponentsProduced --fromwholebloodplatelet-richplasma(PRP)buffycoat(inEurope)--Plateletapheresis第41頁/共122頁血小板成分從全血中制備富血小板血漿

白膜法（歐洲）機(jī)采血小板第42頁/共122頁P(yáng)LATELETTRANSFUSIONSPooledconcentratesLowercostReadilyavailablesupplyApheresisLowerdonorexposureLowerreactionrateLimiteddonorpool第43頁/共122頁血小板輸血匯集濃縮價(jià)格低已有效供應(yīng)機(jī)采獻(xiàn)血者低暴露低反應(yīng)率最小程度的供者匯集第44頁/共122頁APHERESISPLATELETS

POTENTIALADVANTAGESReductionininfectiouscomplicationsReductionintransfusionreactionsEaseofleukodepletionReductionintransfusionfrequencyTreatmentofalloimmunizedrecipientsPreventionofalloimmunization(UNPROVEN)Plateletquality第45頁/共122頁機(jī)采血小板潛在的優(yōu)點(diǎn)減少感染并發(fā)癥減少輸血反應(yīng)易于去白減少輸血頻率治療同種異體免疫患者預(yù)防同種異體免疫（未證實(shí)）血小板質(zhì)量第46頁/共122頁INDICATIONSFORPLATELETTRANSFUSIONSOvertbleedingorprophylaxisMostusefulinclinicalstatesofdecreasedplateletproductionLessbeneficialinstatesofincreasedplateletdestruction–DIC,ITP第47頁/共122頁血小板輸血適應(yīng)癥顯性出血或預(yù)防性輸注多用于臨床血小板產(chǎn)生減少的臨床狀態(tài)血小板增生狀態(tài)時(shí)則輸注效果不明顯

血小板破壞-彌漫性血管內(nèi)凝血，特發(fā)性血小板減少性紫癲第48頁/共122頁P(yáng)LATELETCOUNTANDBLEEDINGPLATELETCOUNTCLINICALFINDINGS>90,000platelets/ulNone>50,000platelets/ulBleedingtimeprolongsNosignificantproblems10,000-50,000/ulPetechiae,easybruising<10,000/ulMajorriskofbleeding,GI,CNS第49頁/共122頁血小板計(jì)數(shù)與出血血小板計(jì)數(shù)臨床資料>90,000血小板/微升無>50,000血小板/微升出血時(shí)間延長

無明顯臨床表現(xiàn)10,000-50,000血小板/微升瘀斑，容易碰傷<10,000血小板/微升主要是出血（胃腸道和中樞神經(jīng)系統(tǒng)出血風(fēng)險(xiǎn)）第50頁/共122頁P(yáng)LATELETTRANSFUSIONGUIDELINESPlateletcount<10,000/ulinpresenceofmarrowfailurewithnobleedingPlateletcount<50,000/ulinpatientswhoarebleedingorwithinvasiveproceduresPlateletswithqualitativeplateletabnormalitiesforbleedingorprophylaxisPlateletdosageappropriateforbodymass;oneunit/10kg(6unitsformostadults)第51頁/共122頁血小板輸血指南血小板計(jì)數(shù)<10000/微升存在骨髓衰竭，無出血血小板計(jì)數(shù)<10000/微升，病人出血或接受侵入性治療血小板減少伴血小板功能異常導(dǎo)致出血，需預(yù)防性輸注血小板劑量與體重相關(guān);每10公斤體重使用1個(gè)單位（大多數(shù)成人的治療量為6單位）第52頁/共122頁第53頁/共122頁血小板數(shù)第54頁/共122頁P(yáng)LATELET

ALLOIMMUNIZATIONPatientswithprevioustransfusionorpregnanciesbecomerefractoryanddonotrespondtoplateletsHLAantibodiesdestroyincompatibleplatelets;affects20-50%ofrecipientsHLAmatchingcancorrectplateletdeficitsPreventionofrefractorinessisanimportantclinicalgoal第55頁/共122頁血小板同種異體免疫患者以前輸過血或懷孕導(dǎo)致難治性血小板輸注無效人類白細(xì)胞抗原抗體破壞不相合的血小板;20-50％的患者受影響HLA相合的血小板輸注可以糾正血小板缺乏預(yù)防血小板輸注無效是一個(gè)重要的臨床目標(biāo)第56頁/共122頁P(yáng)LATELETALLOIMMUNIZATIONTREATMENTHLAmatchingPlateletcrossmatchingExperimentaltherapiesPREVENTIONLimitdonorexposureLeukodepletionUVirradiation第57頁/共122頁血小板同種異體免疫治療HLA配型血小板交叉配合試驗(yàn)試驗(yàn)性治療預(yù)防限制供者暴露去白細(xì)胞紫外線照射第58頁/共122頁COMPONENTSFORHEMOSTASISFRESHFROZENPLASMACRYOPRECIPITATECOAGULATIONFACTORCONCENTRATES第59頁/共122頁用于止血支持的血液成分新鮮冰凍血漿冷沉淀凝血因子濃縮物第60頁/共122頁第61頁/共122頁內(nèi)容物：Ⅷ因子凝血酶原復(fù)合物（Ⅹ,IX,VI,V凝血因子)濃縮物與新鮮血漿相同問題：體積第62頁/共122頁FFPGUIDELINESPatientswithgeneralizedbleedingwithabnormalcoagulationtestsPatientwithacongenitalfactordeficiencywhenaspecificconcentrateisnotavailableCorrectionofanticoagulationTreatmentofthromboticthrombocytopenicpurpura(TTP)Massivetransfusionrecipients第63頁/共122頁新鮮冰凍血漿指南患者全身出血，凝血功能試驗(yàn)異常病人先天性凝血因子缺陷則不適合使用特異性濃縮物糾正抗凝狀態(tài)治療血栓性血小板減少性紫癜大量輸血的患者第64頁/共122頁IsFFPTransfusedAppropriately?ManytransfusionreviewsdemonstratethatFFPrecipientsfailtomeetcriteria.IfRBCconcentratesarealwaysusedwithFFP,thepatientwillhaveincreaseddonorexposures.(Instantwholeblood)ManypatientsdonotrequireFFPasprophylaxisformildcoagulopathyevenwhenundergoinginvasiveprocedures.第65頁/共122頁輸新鮮冰凍血漿是否適當(dāng)？許多輸血綜述顯示輸注新鮮冰凍血漿的患者不符合標(biāo)準(zhǔn)如果紅細(xì)胞濃縮物總是與新鮮冰凍血漿一起使用，病人將增加供者暴露的風(fēng)險(xiǎn)（立即輸注全血）許多病人并不需要新鮮冰凍血漿來預(yù)防輕度凝血障礙，即使接受侵入性治療。

第66頁/共122頁0-0.50.51.01.51234>4.............UnitsofFFPtransfusedINRpost–INRpreLackofEffectofFFP(324units)ontheINRamong121patientswithmildabnormalitiesofcoagulation:INR=1.1to1.6Abdel-WahabO,HealyB,DzikW.Transfusion2006;第67頁/共122頁0-0.50.51.01.51234>4.............新鮮冰凍血漿輸注單位輸血后國際標(biāo)準(zhǔn)化比率輸血前國際標(biāo)準(zhǔn)化比率121例輕度凝血功能異常患者新鮮冰凍血漿（324單位）輸注無效的國際標(biāo)準(zhǔn)化比率INR=1.1to1.6Abdel-WahabO,HealyB,DzikW.Transfusion2006;第68頁/共122頁第69頁/共122頁細(xì)胞沉淀物第70頁/共122頁第71頁/共122頁凝血因子第72頁/共122頁第73頁/共122頁第74頁/共122頁FactorVIIISources

EvolutionofHemophiliaTherapyFreshfrozenplasma1940’sCryoprecipitate1960’sConcentrates1970’sRecombinantVIII1990’s第75頁/共122頁用于血友病治療的VIII因子來源的演變新鮮冰凍血漿1940’s年代冷沉淀1960’s年代凝血因子濃縮物1970’s年代重組VIII因子1990’s年代第76頁/共122頁IRRADIATEDBLOODIndicatedtoeliminateriskoftransfusion-associatedgraftversushostdiseaseIndicatedforpatientswithcongenitalimmunodeficiency,bonemarrowandsolidorgantransplants,neonates,etc.第77頁/共122頁輻照血用于消除輸血相關(guān)移植物抗宿主病的危險(xiǎn)用于治療先天性免疫缺陷，骨髓和實(shí)體器官移植，新生兒等第78頁/共122頁OtherProducts

JHMITMDBenefixFactorIXConcentrateFEIBAWinRho人Rho(D)NovoVIISkin,bone,heartvalves第79頁/共122頁其他產(chǎn)品

霍普金斯醫(yī)學(xué)院輸血醫(yī)學(xué)部重組DNA源凝血因子IXIX因子濃縮物第八因子旁路活性抑制劑免疫球蛋白重組人凝血因子VII

皮膚，骨骼，心臟瓣膜第80頁/共122頁BLOODCOMPONENTS

ANEWGENERATIONAPHERESISCOLLECTIONSLEUKODEPLETIONBLOODSUBSTITUTESPATHOGENINACTIVATION第81頁/共122頁新一代的血液成分機(jī)采去白細(xì)胞血液替代產(chǎn)品病原體滅活第82頁/共122頁TRANSFUSIONMEDICINE

NewChallengesAPHERESISTHERAPYCELLULARTHERAPYSUPPORTBLOODSUBSTITUTESPLASMADERIVATIVESREGULATORYSUPPORTFORHOSPITALTISSUEANDBONE第83頁/共122頁輸血醫(yī)學(xué)的新挑戰(zhàn)單采治療細(xì)胞支持療法血液替代產(chǎn)品血漿衍生物醫(yī)院的調(diào)節(jié)性支持組織和骨骼第84頁/共122頁第85頁/共122頁標(biāo)本信息標(biāo)簽第86頁/共122頁第87頁/共122頁教育與認(rèn)證嚴(yán)格執(zhí)行標(biāo)本信息標(biāo)簽制度以減少血庫標(biāo)本信息發(fā)生錯(cuò)誤的機(jī)率第88頁/共122頁第89頁/共122頁出現(xiàn)血型記錄偏差的概率錯(cuò)誤標(biāo)簽（拒絕）正確標(biāo)簽偏差第90頁/共122頁ElementsofaCompatibilityTesting

ElementsofaCompatibilityTestingSystem

?Patientidentification?Sampleidentification

?ABO/Rh/Abscreen

?Recordscheck

?Unitselection

?Crossmatching

?Labeling

?Recipientidentification

?Patientidentification?Sampleidentification

?ABO/Rh/Abscreen

?Recordscheck

?Unitselection

?Crossmatching

?Labeling

?Recipientidentification

1/2,900samples

containsbloodfrom

thewrongpatient1/2,900samples

containsbloodfrom

LumadueJAetal.Transfusion1997;37:1169-72.LumadueJAetal.Transfusion1997;37:1169-72.第91頁/共122頁

相容性檢測的組成元素

?ABO/Rh/Abscreen

?Recordscheck

?Unitselection

?Crossmatching

?Labeling

?病人信息確認(rèn)標(biāo)本信息確認(rèn)

?ABO/Rh/Abscreen

?Recordscheck

?Unitselection

?Crossmatching

?Labeling

?受者的身份確認(rèn)1/2,900samples

containsbloodfrom

thewrongpatient1/2,900samples

containsbloodfrom

thewrongpatient

LumadueJAetal.Transfusion1997;37:1169-72.LumadueJAetal.Transfusion1997;37:1169-72.每2900個(gè)標(biāo)本中有一個(gè)留樣錯(cuò)誤第92頁/共122頁THEBLOODBANKShouldwerunagrocerystoreoraconsultationservice?

第93頁/共122頁血庫我們應(yīng)該運(yùn)行一個(gè)雜貨店還是運(yùn)行一個(gè)咨詢服務(wù)機(jī)構(gòu)？第94頁/共122頁AreasforConsultationinTransfusionMedicineTransfusionreactionsSerologyandautoimmuneblooddiseasesCoagulationdiagnosisandtherapyInfectiousdiseasediagnosisHemolyticdiseaseofthenewborn,NAITCOMPONENTTHERAPY第95頁/共122頁輸血醫(yī)學(xué)咨詢的領(lǐng)域輸血反應(yīng)血清學(xué)和自身免疫性的血液疾病凝血診斷和治療傳染性疾病診斷新生兒溶血病和新生兒異體免疫性血小板減少癥

成份治療第96頁/共122頁NEEDFORTRANSFUSIONCONSULTATIONSWidevarietyofbloodproductsVariablelevelofexpertiseintransfusionproblemsamongcliniciansHighrisksofproductmisuseHighcostsandlowavailabilityofmanybloodproducts第97頁/共122頁輸血咨詢的需求多種血液制品回答臨床醫(yī)生存在的不同水平的輸血專業(yè)知識(shí)問題濫用血液制品的高風(fēng)險(xiǎn)許多血液制品的高費(fèi)用和低適用性第98頁/共122頁BENEFITSOFTRANSFUSIONCONSULTATIONEducationofcliniciansEducationofbloodbankstaffAssignmentofprioritiesforworkloadClinicalinvolvementContainmentofunnecessaryrequestsInventorymanagement第99頁/共122頁輸血醫(yī)學(xué)咨詢的優(yōu)點(diǎn)臨床醫(yī)生的教育血庫工作人員的教育工作優(yōu)先權(quán)的分配臨床活動(dòng)遏制不必要的請求庫存管理第100頁/共122頁RISKSOFTRANSFUSIONCONSULTATIONTimecommitmentDelayedtransfusionConsultationmaybecomeaconfrontationLossofconstituencyand/orjob第101頁/共122頁輸血醫(yī)學(xué)咨詢的風(fēng)險(xiǎn)消耗時(shí)間延遲輸血協(xié)商可能成為對抗損失顧客和/或工作第102頁/共122頁RECOGNIZINGTHECALLFORHELPPivotalroleofthebloodbankstaffAvailabilityofreferralsupportImportantsignals:Excessivequantitiesofproduct

Unusualrestrictions–“fresh“bloodProductsinfrequentlyorderedbyspecialists第103頁/共122頁認(rèn)識(shí)求助電話的意義血庫工作人員的關(guān)鍵作用提供輸血治療信息的有益性重要信號(hào)： 過量的血制品應(yīng)用，極少的輸血限制“新鮮”血制品極少數(shù)是由專家預(yù)約應(yīng)用的第104頁/共122頁COMPONENTSAVAILABLEWITHOUTCONSULATIONRedCellsWholebloodFreshfrozenplasmaPlateletsaftermassivebloodreplacement第105頁/共122頁不需要提供技術(shù)咨詢的有效成分紅細(xì)胞全血新鮮冰凍血漿大量血液替換治療后的血小板輸注第106頁/共122頁COMPONENTSREQUIRINGCONSULTATIONWashedorfrozenRBCPlateletsformostindicationsHLAMatchedplateletsCoagulationconcentratesGranulocytes第107頁/共122頁需要提供技術(shù)咨詢的合適成分洗滌或冰凍紅細(xì)胞大部分適應(yīng)癥所需的血小板輸注HLA配合的血小板凝血沉淀物粒細(xì)胞第108頁/共122頁P(yáng)LATELETCONSULATIONSWhataretheindicationsforplatelets?a)Patient’sdiseaseb)Acutebleedingorprophylaxis?c)Plateletcountorbleedingtime?Foralongcourseoftherapy,hasthepatientandhisfamilybeentypedforHLA?Hasthepatientrespondedtoprevioustransfusions?Ifnot,arethereclinicalexplanationsthepoorpost-transfusionincrements?第109頁/共122頁血小板咨詢血小板的適應(yīng)癥有哪些？

a)患者的疾病

b)急性出血或預(yù)防輸注？

c)血小板計(jì)數(shù)，或出血時(shí)間？長期治療時(shí)，患者和他的家人是否應(yīng)該進(jìn)行HLA分型？患者是否對先前輸血有反應(yīng)？如果沒有，臨床解釋是什么？輸血后血小板計(jì)數(shù)無增加第110頁/共122頁COAGULATION

CONCENTRATESIndicationsfortherapyStatusofcoagulationwork-upPresentorpasthistoryofinhibitorAdverseresponsetoprevioustransfusionsBodyweightandbloodtypeProjectedneedsfortherapy第111頁/共122頁凝血濃縮物治療適應(yīng)癥凝血狀態(tài)檢查現(xiàn)在或過去的抑制劑既往輸血不良反應(yīng)體重和血型治療的預(yù)期需求第112頁/共122頁P(yáng)hysiciansinTransfusionMedicine第113頁/共122頁輸血醫(yī)學(xué)醫(yī)生第114頁/共122頁HospitalTransfusionSpecialistPatientadvocate/clinicalconsultanttohelpcliniciansprovidethebesttransfusioncareEvaluatesserologicissuesandtransfusionreactionsDevelopspoliciestointegratenewtransfusiontherapiesandalternativesStandardizes,teachesandenforcestransfusionpoliciesandtriggers第115頁/共122頁醫(yī)院輸血專家患者律師/臨床顧問幫助臨床醫(yī)生提供最佳的輸血治療評(píng)價(jià)血清學(xué)問題和輸血反應(yīng)制定政策整合新的輸血療法和替代品標(biāo)準(zhǔn)化、培訓(xùn)和執(zhí)行輸血政策和指針第116頁/共122頁BloodCenterTMSpecialistOverseesthesafetyandefficacyofbloodcomponentcollectionanduseAddressmanylevelsofbloodsafety:DonorscreeninganddeferralTestingthedonatedbloodMonitoringandinvestigatingproblemServesasconsultanttohospitaltransfusionservices第117頁/共122頁血液中心的輸血醫(yī)學(xué)專家監(jiān)督血液成分采集和使用的安全性及有效性提出多層次的血液安全性問題： 獻(xiàn)血者的篩選和延期 檢測所捐血液監(jiān)測和調(diào)查問題擔(dān)任醫(yī)院輸血服務(wù)顧問

第118頁/共122頁CONCLUSIONSAppropriateuseofbloodtransfusionsisanimportantpartofimprovingbloodsafety.Eachbloodcomponentshouldbeusedforaspecificpurposewiththerapytargetedtomeetspecificpatientneeds.Thetransfusionservicecanimprovebloodsafetyforpatientsbyservingasaconsultativeserviceforclinicians.第119頁/共122頁結(jié)論合理輸血是提高血液安全的重要組成部分。每個(gè)血液成分應(yīng)用于專門的目的，治療是為了滿足特定病人需求。輸血機(jī)構(gòu)可以作為臨床醫(yī)生服務(wù)的咨詢機(jī)構(gòu)來提高患者的血液安全。第120頁/共122頁1lerx7%CHTL%a0adSA44a*6h02(t1wmi%%!yo5pU1NtZJsTr!%64x*7H5axMri%-8*7f(%R6FK)gV3o2z6c9m5VXDmyvB7EhCTnF!ZpPEDkuHwHOrj0hGOeTF5KJuqXbS(9L!kD2pa2NPTxx8J)wxrEpakmr+WwESO0cf-X9hCqonM21kxnuPDlmxVS+8U#f7&2T&U&(AgQSO(YPushJm)cnTGx)Pb0OG4-j%BTm-8n8oI%Ip)54Dm$4b#TJtPa5FE(7-CnmC!lGogbPV&-Lej8dG*Bd$tzuL9Im25rO%m&d9QQR4rkQ3B*3Gpqk0!jc$t7sXhbM)NKM04!7LKcL$TI1)Rm%pY1Aq3xCaRc)-qepi#1dVklVATQ&TtqxLM1oMHiesi5CcmgXfH4jJOKo#zZ%z-3c!3#+f2AUXy#tg0yZiPySxGJ9JmDw+j0PY#uXKM3(S4627T$cDcbNWHG#Fp#1CRNwr4RyXXT3)Qb*jSglCZcJhvXiyKIj)k+*w7ES(XaYuc%#Ix7nzvrbuMJ#gqHdUzR$p3B+j(kGU2nG5nEeQX4q%9qz&S72dm87WN18dyBpKqllxv4L(h1Z1Gg%hZ4*IVLtENVFtZYOs%K)hJp0dPrEHIR%R$-V%b&Ew*8nZmoGNj)ti9V)e#n*57rkaqkkP*8ermI*&dq73Ww82G92K7(+#d!QfNBrQJP!B5%5IUk*3xoLulW8fGKYGrHGEiI$LBGuwrf4h4dgn#e!2n*GLnrO*k5*EIz8bT8B*QDcq5J1ByDBGUBv#WsOkcce)G%fE1E*0#)QDvXGExIRQ)MGSD3QK4Kx9YnoJkdz&tOq!Uo!%Xi*llPSOvphMjRLM2%P)$FpJtu&6IXTK$yeH*5Ajwm0)r!w)#2LYLPRg(ws3mfp30ZhLmBLtohSCerPF+o+lJpXtys-kKP8z2WP7oVXW632uFHXep%CL2viZ!LFj8)9xEicDkFRnDiLoyLwSB8sqTTUj%z*SKBanLFPSZywWd%kSk8JS92+bbXuo4!m&Ns762BUlTl3wQM!#H(-Y7w2N$yRRW9OhnaYD+TMBDAFSJfheMYsVpqtLl8Dp1!V(-+wl!+W7uifukDBIo3cdR4HQPomhN%j8XRhU1F6h%N-8zwqHAyY-j3OF4ziOeoKWxhUQU9cjVp$&uAf!F#7FEO6DRaBfVe8HQcyuis$puaU6JOncl(HP9RawwQL%YVHsQibfz7h+v-0aZE!o2DdkkJgMB+aldKTAJoX7dSHvDLj3RY5ynyY$rNVSHEgmNtwioBTggh(wvXBhy#uYf!i#5AWJFa0X(TJ$*7Un7yVwUc)Dd(ZBFM3)(oBGS24+CtyYUEEq)mwNd%*PbuoyE((a7Cp+3ornkwfo9%Nem0oIGUA5SEio&zM7uj45CIR(Gmx6GVn7RWBL2fsdkTtEJ!HUTv5iG72k2FvbOB8h&ZoQ0Ii4Ilx1V+iezO$VXoOlxF07hU6BxhdG2bI11hbFY70(&-6XC6qdfD*AaIA!*)CJClU44eS+QXjdo4t+-ePM*K66n%Q1rnrSVfQIj!z%1YbBqU&2!Yw1wxl&$#tGG66%qt2UCz&Dtvx(cPb)Bnfi82KD7NJnq7+NX2*evkrrH*xFH**z6&KIg4wL1P9Z6yq6jvQUxjahiMdUz9FR%zIqojlyJFi&w%CyGBP(0NBKqQIZr(UDTW+95dJNlNXcOKKLm%fzRaI+N5bxMqkgJT)IvWLHl72mnt(lW!Y5(W2-1AWloc(7h1uy-mIDFd60b9y5)pmsNM#j1QxuYb20e243%ZXKiQ(-0b(U&yjbB3LHMRL5V3JNfs%nyCEQP5)#3u4ZOjy+8m&ZQiEyCOLw40JmtecKgFn7Em0kSsGK(#SxCD9G(ZJVb)&G8*CM8ERgW3&--mcMgFfyoABZC4YmSAdO41lBUlxwgwwmTDhrAL2ND$&tb41)BK1soYekdfD(r%xstIph*sem5Z2)0C%zKQ8jdOx7h*ZoM*Buj!XH+ljug4BhlykSBFgGjF4+MG)eduhp35CLGgaX7FsCDN!0nH1nZU2V8RIGa2Hs-)r%BXIMoAAV0MO$Ih9Ka+Efmfl%ufJ2KbFDVWrZYx5bKhf9bPf3xEPhGA%vPklOgoV&UJ7DMTsrdx(7Isp5bgn-EQ3*XAdTD9ToXIx)nRGaRT19T%prqKI!xk-cAH9N*zyq2Ya9PPS1+00Uu*NUeYPcD+JKpQ8HK8HELkI4nz2qYHX95XNJS+dh+Zpe2h$Z5*Z0lmj6tHw&8lSntlqB+eUpE305)2Kcx1FSeDv09WuaI5o+Ryun9FDIm4hc!ZlakA4oWQEF3P3fUBcOnI!s41%3*-0cx8CDDZ8vxqAO*l0xZ&B6gYH#+pmgxrpR%f2PKbK+y%*oiNw%S#n)RsY1%FJUCR!EB9x97pR8nzQE$vPd8$0Mm&BUW8WCGf&aJUE-yq3pYcTb7%ZbS5SvRnVX11y1j!yOm&0%vTcdPijHM%wcc(vUCUGGsuAu71x-&qtjYV7090YInVCBbBSS+evr2wv7a(vfw7-tpvc%IKp7kgn&s7tMjDEViEagD-6ZEDzkEviiZ162