减少肝移植围手术期输血相关策略的研究进展

肝移植手术一直存在大量失血和输血的问题.在过去的二十年中,随着肝移植技术的不断成熟,围手术期输血量急剧减少,无输血肝移植成为现实.由于出血和输血都与肝移植的不良预后相关,减少出血和不必要的输血成为了肝移植围手术期的关键目标.本文总结了肝移植围手术期异体输血的不良影响、终末期肝病患者的凝血功能监测、肝移植受者的输血管理以...     

The role of tranexamic acid in a comprehensive blood management protocol for total hip and knee arthroplasty patients

Allogeneic blood transfusions during total hip or knee arthroplasty have been associated with increased risks for perioperative complications as well as increased medical costs. A multi-modal approach toperioperative management of the patients to minimize the risk for an allogeneic blood transfusion can help both the patient and the health care system. This approach involves optimizing the patients’ hemoglobin preoperatively, utilizing a variety of techniques intraoperatively including tranexamic acid to minimize blood loss, and using patient specific transfusion triggers post-operatively. In particular, the incorporation of tranexamic acid to the perioperative management of total hip and total knee replacement patients dramatically decreased the rate of allogeneic blood transfusions in our hospital.     

Anaemia and blood transfusion: incorporating patient blood management

Both red blood cell (RBC) transfusion and anaemia or low haematocrit increase morbidity and mortality associated with surgery. Chronic anaemia in the elective patient carries a small risk in non-haemorrhagic surgery. Where bleeding is anticipated anaemia should be treated medically to avoid (RBC) transfusion which will increase the risk to the patient. Major bleeding (MB) has the biggest impact on adverse outcomes. Acute anaemia is caused by surgical bleeding and requires RBC transfusion to keep the haematocrit (Hct) above 21% and haemoglobin (Hb) above 7 g/dl in patients without coronary artery disease (CAD) and between Hct 24–27% or Hb >8 g/dl in patients with CAD. Having a patient blood management programme can mitigate the problem. Medical, surgical and anaesthetic planning are paramount to avoid bleeding and transfusion which together have a significant impact on adverse outcomes for the patient.     

Pr?operative An?mie in der Orthop?die

In a national audit of elective orthopedic surgery conducted in the US, 30% of patients were found to have hemoglobin (Hgb) levels <?13?g/dl at preadmission testing. Preoperative anemia has been associated with increased mortality and morbidity after surgery, increased allogeneic blood transfusion therapy and increased rates of postoperative infection leading to a longer length of hospital stay. Because of the risks associated with allogeneic blood transfusions according to German law patients have to be offered the option of autologous transfusion if the risk associated with allogeneic blood transfusion is >?10%. However, one of these measures, the autologous blood donation, can exaggerate anemia and can increase the overall transfusion rates (allogeneic and autologous). As autologous procedures (autologous blood donation and cell salvage) are not always appropriate for anemic patients together with an expected shortage of blood and because preoperative anemia is associated with perioperative risks of blood transfusion, a standardized approach for the detection, evaluation and management of anemia in this setting was identified as an unmet medical need. A panel of multidisciplinary physicians was convened by the Society for Blood Management to develop a clinical care pathway for anemia management in elective surgery patients for whom blood transfusion is an option. In these guidelines elective surgery patients should have Hgb level determination at the latest 28?days before the scheduled surgical procedure. The patient target Hgb before elective surgery should be within the normal range (normal female ???120?g/l, normal male????130?g/l). Laboratory testing should take place to further determine nutritional deficiencies, chronic renal insufficiency and/or chronic inflammatory diseases. Nutritional deficiencies should be treated and erythropoiesis-stimulating agent (ESA) therapy should be used for anemic patients in whom nutritional deficiencies have been ruled out and/or corrected.     

Preoperative anemia in orthopedic surgery: clinical impact, diagnostics and treatment

In a national audit of elective orthopedic surgery conducted in the US, 30% of patients were found to have hemoglobin (Hgb) levels ?10%. However, one of these measures, the autologous blood donation, can exaggerate anemia and can increase the overall transfusion rates (allogeneic and autologous). As autologous procedures (autologous blood donation and cell salvage) are not always appropriate for anemic patients together with an expected shortage of blood and because preoperative anemia is associated with perioperative risks of blood transfusion, a standardized approach for the detection, evaluation and management of anemia in this setting was identified as an unmet medical need. A panel of multidisciplinary physicians was convened by the Society for Blood Management to develop a clinical care pathway for anemia management in elective surgery patients for whom blood transfusion is an option. In these guidelines elective surgery patients should have Hgb level determination at the latest 28?days before the scheduled surgical procedure. The patient target Hgb before elective surgery should be within the normal range (normal female ≥?120?g/l, normal male?≥?130?g/l). Laboratory testing should take place to further determine nutritional deficiencies, chronic renal insufficiency and/or chronic inflammatory diseases. Nutritional deficiencies should be treated and erythropoiesis-stimulating agent (ESA) therapy should be used for anemic patients in whom nutritional deficiencies have been ruled out and/or corrected.     

促红细胞生成素在心血管手术中应用的研究进展

心血管手术患者具有病情危重、合并症多,异体输血率高等特点。在血制品供需不平衡的前提下,异体输血可增加患者术后并发症。促红细胞生成素在心血管手术围术期应用具有明显的优势,有望为心血管手术围术期患者提供更好的血液和器官保护管理。本文就促红细胞生成素在心血管手术围术期临床应用价值和局限性的最新进展进行综述,为临床医师在心血管手术围术期患者使用促红细胞生成素提供参考。     

Intraoperative blood loss in orthotopic liver transplantation: The predictive factors

Liver transplantation has been associated with massive blood loss and considerable transfusion requirements. Bleeding in orthotopic liver transplantation is multifactorial. Technical difficulties inherent to this complex surgical procedure and pre operative derangements of the primary and secondary coagulation system are thought to be the principal causes of perioperative hemorrhage. Intraoperative practices such as massive fluid resuscitation and resulting hypothermia and hypocalcemia secondary to citrate toxicity further aggravate the preexisting coagulopathy and worsen the perioperative bleeding. Excessive blood loss and transfusion during orthotopic liver transplant are correlated with diminished graft survival and increased septic episodes and prolonged ICU stay. With improvements in surgical skills, anesthetic technique, graft preservation, use of intraoperative cell savers and overall perioperative management, orthotopic liver transplant is now associated with decreased intra operative blood losses. The purpose of this review is to discuss the risk factors predictive of increased intra operative bleeding in patients undergoing orthotopic liver transplant.     

The safety and efficacy of "bloodless" cardiac surgery

Nearly 20% of blood transfusions in the United States are associated with cardiac surgery. Despite the many blood conservation techniques that are available, safe, and efficacious for patients undergoing cardiac surgery, many of these operations continue to be associated with significant amounts of blood transfusion. Although surgical bleeding after cardiopulmonary bypass is a common problem as reflected by the substantial use of blood products, it is the individual physician and institutional behavior that have been identified as reasons for transfusion and not necessarily patient comorbidity or blood loss. Transfusion rates in cardiac surgery remain high despite major advances in perioperative blood conservation, with large variations among individual centers. The adoption of available blood conservation techniques, either alone or in combination in patients undergoing cardiac surgery, could result in an estimated 75% reduction of unnecessary transfusions. The success of previously reported blood conservations programs in cardiac surgery should call for a reevaluation of allogeneic transfusion practices in patients undergoing cardiac surgery. By applying the numerous reported blood conservation strategies for the management of patients presenting for cardiac surgery, we can preserve our dwindling blood resources and help alleviate some of the direct costs of blood as well as the indirect costs of treating noninfectious and infectious complications of transfusion.     

Perioperative Blood Management Strategies for Total Knee Arthroplasty

Total knee arthroplasty (TKA) often causes a significant amount of blood loss with an accompanying decline in hemoglobin and may increase the frequency of allogeneic blood transfusion rates. Unfortunately, allogeneic blood transfusions have associated risks including postoperative confusion, infection, cardiac arrhythmia, fluid overload, increased length of hospital stay, and increased mortality. Other than reducing the need for blood transfusions, reducing perioperative blood loss in TKA may also minimize intra‐articular hemorrhage, limb swelling, and postoperative pain, and increase the range of motion during the early postoperative period. These benefits improve rehabilitation success and increase patients’ postoperative satisfaction. Preoperative anemia, coupled with intraoperative and postoperative blood loss, is a major factor associated with higher rates of blood transfusion in TKA. Thus, treatment of preoperative anemia and prevention of perioperative blood loss are the primary strategies for perioperative blood management in TKA. This review, combined with current evidence, analyzes various methods of blood conservation, including preoperative, intraoperative, and postoperative methods, in terms of their effectiveness, safety, and cost. Because many factors can be controlled to reduce blood loss and transfusion rates in TKA, a highly efficient, safe, and cost‐effective blood management strategy can be constructed to eliminate the need for transfusions associated with TKA.     

全膝关节置换术术中止血药物的应用策略

全膝关节置换术(TKA)时骨与软组织出血常会导致大量血液丢失。初次置换时累计失血量可达500~1500ml。围手术期大量失血常常需要同种异体输血来维持血红蛋白以及红细胞压积的水平。同种异体输血常常导致免疫抑制,输血反应,移植物抗宿主病和感染的发生。为了避免这些问题并且降低输血的费用,可采用多种术中药物治疗策略。目前,这些药物包括氨甲环酸,6-氨基己酸,纤维蛋白,凝血酶,肾上腺素以及去甲肾上腺素。然而,这些药物的效果以及成本收益往往不同。我们对全膝关节置换术术中药物治疗方法进行总结,并讨论应用药物可能带来的并发症。     

Use of Blood Products in Pediatric Cardiac Surgery

In pediatric cardiac surgery, there is a substantial gap between published recommendations or guidelines for blood product use and clinical practice. The drawbacks of blood transfusion are well acknowledged though. The aim of this paper is to present the rationale for packed red blood cells, fresh frozen plasma (FFP), and platelets used in pediatric patients. Blood hemoglobin level is the current trigger used for packed red blood cells transfusion, though commonly admitted to be suboptimal. An increase in hemoglobin level is likely to be associated with an increase in blood oxygen content and blood oxygen delivery. However, above a critical level of hemoglobin, normovolemic anemia is well tolerated, and any increase in hemoglobin will fail to increase oxygen consumption and therefore to improve end‐organ oxygen supply. FFP is one way to address the coagulation factors deficiency induced by hemodilution, consumption, or hepatic insufficiency. The volume needed to increase these factors is not negligible. To avoid dilution and/or fluid overload, the use of clotting factor concentrate is recommended. The same remark can be made regarding the treatment of antithrombin III deficiency. Platelets infusion should be restricted to bleeding patients with thrombocytopenia and without surgical bleeding. In clinical studies, the prevention of bleeding through prophylactic infusion of platelets proved to be useless. Optimizing the use of blood products (avoiding overuse, underuse, and inappropriate use) is a challenging task in pediatric cardiac surgery. Data or guidelines cannot replace clinical judgment and the decision to transfuse is left to individual discretion, but the medical community needs to optimize its transfusion practice, otherwise policy‐makers without similar expertise may step in to regulate the use of blood products.     

An innovative simple technique of blood conservation in adult patients with tetralogy of Fallot and severely raised hemoglobin

The adult patients of tetralogy of Fallot often present with high hemoglobin levels. High hemoglobin and hematocrit on cardiopulmonary bypass (CPB) are associated with increased hemolysis, plasma free hemoglobin, renal dysfunction or failure, postoperative bleeding, exploration for bleeding, and increased requirement of allogeneic blood and blood products. Despite the presence of high hemoglobin and its association with adverse outcome, blood conservation is rarely practiced in these patients because of the fear of possible hemodynamic instability, and hypoxemic spell. We describe an innovative, simple technique of blood conservation for adult patients of tetralogy of Fallot with severely raised hemoglobin. With this technique, hemoglobin can be normalized on CPB; moreover, there is no fear of hypoxemic spell or hemodynamic instability. Furthermore, the blood conserved is readily available for transfusion in the perioperative period, if needed.     

Factors influencing blood loss and allogeneic blood transfusion practice in craniosynostosis surgery

Objective/Aims: To identify factors influencing perioperative blood loss and transfusion practice in craniosynostotic corrections. Background: Craniosynostotic corrections are associated with large amounts of blood loss and high transfusion rates. Methods: A retrospective analysis was performed of all pediatric craniosynostotic corrections during the period from January 2003 to October 2009. The primary endpoint was the receipt of an allogeneic blood transfusion (ABT) during or after surgery. Pre‐, intra‐, and postoperative data were acquired using the electronic hospital registration systems and patients’ charts. Results: Forty‐four patients were operated using open surgical techniques. The mean estimated blood loss during surgery was 55 ml·kg^?1. In 42 patients, red blood cells were administered during or after surgery with a mean of 38 ml·kg^?1. In 23 patients, fresh frozen plasma was administered with a mean of 28 ml·kg^?1. A median of two different donors per recipient was found. Longer duration of surgery and lower bodyweight were associated with significantly more blood loss and red blood cell transfusions. Higher perioperative blood loss and surgery at an early age were correlated with a longer duration of admission. Conclusions: In this study, craniosynostotic corrections were associated with large amounts of blood loss and high ABT rates. The amount of ABT could possibly be reduced by appointing a dedicated team of physicians, by using new less‐invasive surgical techniques, and by adjusting anesthetic techniques.     

Intraoperative cell salvage with autologous transfusion in liver transplantation

Liver transplant(LT) is the primary treatment for patients with end-stage liver disease. About 25000 LTs are performed annually in the world. The potential for intraoperative bleeding is quite variable. However, massive bleeding is common and requires blood transfusion. Allogeneic blood transfusion has an immunosuppressive effect and an impact on recipient survival, in addition to the risk of transmission of viral infections and transfusion errors, among others.Techniques to prevent excessive bleeding or to use autologous blood have been proposed to minimize the negative effects of allogeneic blood transfusion.Intraoperative reinfusion of autologous blood is possible through previous selfdonation or blood collected during the operation. However, LT does not normally allow autologous transfusion by prior self-donation. Hence, using autologous blood collected intraoperatively is the most feasible option. The use of intraoperative blood salvage autotransfusion(IBSA) minimizes the perioperative use of allogeneic blood, preventing negative transfusion effects without negatively impacting other clinical outcomes. The use of IBSA in patients with cancer is still a matter of debate due to the theoretical risk of reinfusion of tumor cells. However, studies have demonstrated the safety of IBSA in several surgical procedures, including LT for hepatocellular carcinoma. Considering the literature available to date, we can state that IBSA should be routinely used in LT, both in patients with cancer and in patients with benign diseases.     

Anemia and Transfusions in Patients Undergoing Surgery for Cancer

Preoperative, operative, and postoperative factors may all contribute to high rates of anemia in patients undergoing surgery for cancer. Allogeneic blood transfusion is associated with both infectious risks and noninfectious risks such as human errors, hemolytic reactions, transfusion-related acute lung injury, transfusion-associated graft-versus-host disease, and transfusion-related immune modulation. Blood transfusion may also be associated with increased risk of cancer recurrence. Blood-conservation measures such as preoperative autologous donation, acute normovolemic hemodilution, perioperative blood salvage, recombinant human erythropoietin (epoetin alfa), electrosurgical dissection, and minimally invasive surgical procedures may reduce the need for allogeneic blood transfusion in elective surgery. This review summarizes published evidence of the consequences of anemia and blood transfusion, the effects of blood storage, the infectious and noninfectious risks of blood transfusion, and the role of blood-conservation strategies for cancer patients who undergo surgery. The optimal blood-management strategy remains to be defined by additional clinical studies. Until that evidence becomes available, the clinical utility of blood conservation should be assessed for each patient individually as a component of preoperative planning in surgical oncology.     

Intraoperative autotransfusion is associated with modest reduction of allogeneic transfusion in prosthetic hip surgery

Background: The efficacy of intraoperative salvage and washing of wound blood and the predictors of allogeneic red cell transfusions in prosthetic hip surgery are insufficiently known.
Methods: In 96 patients, undergoing primary or revision surgery, salvaged and washed red cells and, if necessary, allogeneic blood were used to keep haematocrit not lower than 33%. The bleeding of red cells during hospital stay was calculated from the red cell balance. The preoperative red cell reserve (millilitres of red cells in excess of a haematocrit of 33%) was estimated and the difference between this volume and the total bleeding of red cells was retrospectively used to classify patients with regard to the need for red cells. Stepwise regression analysis was used to define patient-related variables associated with allogeneic blood transfusion.
Results: Preoperative knowledge of the type of operation (primary, revision), the preoperative red cell reserve, and the body mass could predict roughly half of the need for banked blood (r²=0.45). Only one-third of the total bleeding of red cells was retransfused. For complete avoidance of allogeneic blood, autotransfusion was most effective in patients with a moderate need (0–4 u). However, 32% of such patients required allogeneic blood.
Conclusions: Autotransfusion has a limited efficacy to decrease the need for allogeneic blood, and other blood-saving methods should be added for this purpose. It is difficult to predict the need for allogeneic blood preoperatively.     

Patients With Infected Total Hip Arthroplasty Undergoing 2-Stage Exchange Arthroplasty Experience Massive Blood Loss

Background

Two-stage exchange arthroplasty is the preferred treatment for chronic periprosthetic joint infection following total hip arthroplasty (THA). These patients are at high risk of substantial blood loss and perioperative blood transfusion. Our study aimed at determining risk factors for blood transfusion during a 2-stage exchange for infected THA.

Simultaneous Bilateral Total Hip Arthroplasty With Contemporary Blood Management is Associated With a Low Risk of Allogeneic Blood Transfusion

BackgroundThere is a paucity of data on blood loss and the risk of allogeneic blood transfusion after simultaneous bilateral total hip arthroplasty (SBTHA) with contemporary blood management including neuraxial anesthesia, routine tranexamic acid use, and a restrictive transfusion protocol. As such, we sought to determine the in-hospital outcomes of SBTHA, specifically analyzing blood loss and the rate and risk factors for transfusion.MethodsWe identified 191 patients who underwent SBTHA at a single institution from 2016 to 2019. No drains were utilized and no patients donated blood preoperatively. Mean age was 59 years with 96 females (50.3%). The surgical approach was posterior in 138 (72.3%) and direct anterior in 53 (27.7%) patients. We analyzed blood loss, the rate of allogeneic blood transfusions, and in-hospital thromboembolic complications. We analyzed risk factors for transfusion with a logistic regression analysis.ResultsTwenty-two patients (11.5%) underwent allogeneic blood transfusion. All transfused patients were female. Univariate analysis revealed female gender as a transfusion risk factor since it had statistically significant higher proportion in the transfusion group than the nontransfusion group (100% vs 43.5%, respectively, P < .001). We did not identify any other singular significant risk factors for transfusion in a multivariable regression analysis. However, females with a preoperative Hb <12 had an elevated risk of transfusion at 37.5% (15/40 patients).ConclusionWith contemporary perioperative blood management protocols, there is a relatively low (11.5%) risk of a blood transfusion after SBTHA. Females with a lower preoperative Hb (<12 g/dL) had the highest risk of transfusion at 37.5%.     

Alternative Procedures for Reducing Allogeneic Blood Transfusion in Elective Orthopedic Surgery

Perioperative blood loss is a major problem in elective orthopedic surgery. Allogeneic transfusion is the standard treatment for perioperative blood loss resulting in low postoperative hemoglobin, but it has a number of well-recognized risks, complications, and costs. Alternatives to allogeneic blood transfusion include preoperative autologous donation and intraoperative salvage with postoperative autotransfusion. Orthopedic surgeons are often unaware of the different pre- and intraoperative possibilities of reducing blood loss and leave the management of coagulation and use of blood products completely to the anesthesiologists. The goal of this review is to compare alternatives to allogeneic blood transfusion from an orthopedic and anesthesia point of view focusing on estimated costs and acceptance by both parties.     

Predictive factors for perioperative blood transfusions in rectal resection for cancer: A multivariate analysis of a group of 212 patients

BACKGROUND. In colorectal cancer surgery, allogeneic blood transfusions have reportedly been associated with higher rates of postoperative complications and tumor recurrence. However, because of the increased cost of alternative types of blood transfusions (eg, the use of autologous blood or erythropoietin administration), their routine use cannot be recommended. This study evaluated the risk factors for perioperative blood transfusions in resection for rectal cancer in order to identify patients who could benefit from these methods. METHODS. From 1990 to 1997, 212 consecutive patients who underwent elective rectal resection for cancer were reviewed. The associations between perioperative heterologous blood transfusion and 18 patient-, tumor-, surgical-, and treatment-related variables were assessed by univariate and multivariate analysis. RESULTS. Of the 212 patients, 72 (34%) received transfusions. Multivariate analysis revealed that 5 preoperative variables were significant risk factors for perioperative blood transfusion: age > 65 years (P =.03), body mass index > 27 kg/m(2) (P =.04), preoperative hemoglobin < or = 12.5 g/dL (P <.0001), American Society of Anesthesiologists status > 2 (P =.024), and additional surgical procedures (P =.018). In patients with anemia, the risk of transfusion was at least 47% in patients with 1 other risk factor or more. In nonanemic patients, the risk of transfusion was under 11% in patients with 1 risk factor or none, but increased to 47% in those with 2 or more risk factors. CONCLUSIONS. Our analysis of risk factors for perioperative blood transfusion in rectal resection for cancer must be considered to constitute guidelines for a more responsible use of the expensive alternatives to allogeneic blood transfusion.