预贮式自体输血和急性等容性血液稀释联合应用于颅脑外科手术的临床研究

目的 探讨在颅脑外科手术中联合应用预贮式自体输血和急性等容性血液稀释的安全性和临床效果。方法 63例病人随机分为预贮式自体输血组(A组31例)和联合应用预贮式自体输血和急性等容性血液稀释组(B组32例)。两组在采血前、术前即刻放血前、放血后、回输自体血后、术后第1天分别测定Hb、Hct、Pt及PT、APTT、FIB，监测MAP、CVP、SpO2、HR，两组出血量、输异体血量。结果 A、B组Hb、Hct术中降低，与术前比较有显著性差异(P＜0．05)，回输自体血后回升。A、B两组PT、APTT术中延长，FIB和Pt未见明显改变。两组术中血流动力学稳定。A组采血量明显少于B组(P＜0．05)，输异体血量明显多于B组（P＜0．05)。结论 联合应用预贮式自体输血和急性等容性血液稀释有明显节血效应，对血液生理学影响小，血流动力学稳定。     

急性高容量血液稀释联合控制性降压和自体血回收在全髋关节置换术中的应用

目的 观察急性高容量血液稀释(AHH)联合控制性降压(CH)和自体血回收回输技术应用于全髋关节置换术的临床效果与安全性.方法 60例全髋关节置换术,用抽签法随机均分成观察组(A组)和对照组(C组),A组全麻诱导后30 min内输入6%羟乙基淀粉130/0.4 15 ml/kg.手术开始时用硝酸甘油行CH,维持MAP(65±5)mmHg,并应用自体血液回收仪回收回输术野出血.C组除未行CH外,余操作均同A组,两组术中连续监测HR、MAP、中心静脉压(CVP);记录出血量、异体血输入量及手术时间,并分别于AHH前、AHH后、术毕测定Hb、血细胞比容(Hct)及凝血酶原时间(PT)、活化的部分凝血酶原时间(APTT)和纤维蛋白原(FG).结果 A组失血量(515±123)ml和回输洗涤红细胞量(275±53)ml均显著低于C组(950±183)ml和(425±97)ml(P<0.01);两组Hct、Hb在AHH后和术毕较AHH前降低(P<0.01),两组PT、APTT在AHH后和术毕均长于AHH前(P<0.01),而FG低于AHH前(P<0.01),但均在正常范围.A组未输入异体血,C组3例输入少浆血2 U,5例输入新鲜冰冻血浆200ml.两组均无肺水肿、心衰及创面异常出血等并发症.结论 AHH联合CH可安全用于全髋关节置换术,并明显减少术中出血量,术中配合自体血回收回输技术可减少甚至避免异体输血.     

控制性降压联合自体血回输在脊柱手术中的应用

目的 探讨控制性降压联合自体血回输技术应用于复杂脊柱外科大手术的临床效果及安全性. 方法 将40例脊柱外科大手术的患者用抽签法随机分为两组(每组20例):控制性降压联合自体血回输组(A组)和非自体血回输组(B组).A组全麻诱导后,术中用硝酸甘油行控制性降压,维持平均动脉压(mean arterial pressure,MAP)(65±5) mmHg(1mmHg=0.133 kPa),并用血液回输仪回收术野出血;B组未行自体血回输;两组术中血细胞比容(hematocrit,Hct)低于25％即输库血.两组术中连续监测心率(heart rate,HR)、MAP、心电图(electrocardiogram,ECG)和中心静脉压(central venous pressure,CVP).记录两组患者术中出血量、异体输血量及输血相关并发症,术前和术后24 h红细胞(red blood cell,RBC)、血红蛋白(hemoglobin,Hb)、Hct、血小板(platelet,PLT)及凝血酶原时间(prothrombintime,PT)、活化部分凝血酶原时间(activeated partial thromboplasting time,APTT)和纤维蛋白原(fibrinogen,FG). 结果 A组出血量(1 120±510) ml与B组(1 524±457) ml比较,差异有统计学意义(P＜0.05);A组输异体血发生率(10％)显著少于B组(100％)(P＜0.01);术后24 h两组患者RBC、Hb、Hct、PLT、PT、APTT和FG与术前比较差异有统计学意义(P＜0.05),但都在正常范围内,两组间比较差异无统计学意义(P＞0.05);两组均无肺水肿、心力衰竭及创面异常出血并发症. 结论 控制性降压复合术中自体血回输在复杂脊柱手术中的应用是安全可靠的,能明显减少出血量,减少甚至避免异体血输入.     

Sonoclot评价术中自体和异体输血对老年人凝血功能的影响

目的观察老年患者术中回收式自体输血前后凝血参数的变化。方法24例择期手术的老年患者随机分为回收式自体输血组(观察组)或异体输血组(对照组)。观察组12例,回输经血液回收仪洗涤处理的自体血;对照组12例,输异体浓缩红细胞。分别取术前、输血前和输血后的静脉血,测定血常规、凝血酶原时间(PT)、活化的部分凝血活酶时间(APTT),同时Sonoclot仪测定血凝曲线的各项指标。结果两组术前、输血前和输血后Hb、血小板计数(Plt)、纤维蛋白原(FIB)、APTT及PT水平变化趋势相似。观察组的血块凝结速率(CR)值自体血回输前与手术前相比变化明显(P<0.05),但与对照组比差异无统计学意义。两组间Sonoclot仪其他各项指标在各测定点差异也无统计学意义。结论术中回收式自体输血与异体输血相比对老年人凝血功能的影响差异无统计学意义。     

自体血回输技术在脑外伤手术患者中的应用

目的探讨回收式自体血回输在脑外伤手术中的应用效果。方法本院2012年1月至2013年12月,实施脑外伤手术,选择无自体血回输禁忌症且预计出血量大于600ml的90例患者随机分成两组,每组45例：对照组A组、术中回收式自体血回输组（研究组）B组,对患者手术前（T1）、手术结束（T2）、术后24小时（T3）患者的凝血功能及红细胞（RBC）、血红蛋白（HGB）、红细胞压积（Hct）进行检测,记录输血量,以及评价并发症。结果应用回收式自体血回输组48%的患者避免了术中、术后异体血的输入,而对照组仅9%的患者不需输入异体血。以对照组相比,自体血回输患者异体输血量平均每例比对照组少输293ml,自体血回输再回收率约49%,各组术前、手术结束、术后24小时血液中的RBC、Hb、Hct及凝血功能检测数据大致正常。结论自体血液回输用以脑外伤患者是安全且有效的方法,可以及时获得大量新鲜血液对患者进行抢救,同时节省异体血用量,并且可以避免血液传播性疾病的发生,对患者影响小、并发症低,可安全应用于脑外伤手术。     

Rh(D)阴性血型病人剖宫产术中成分式自体输血的安全性

目的 评价Rh(D)阴性血型病人剖宫产术中成分式自体输血的安全性.方法 拟行剖宫产术的Rh(D)阴性血型病人30例,年龄20～35岁,体重50～80 kg,ASA分级Ⅰ或Ⅱ级.静脉输注乳酸钠林格氏液7 ml/kg后经桡动脉采血,采血速率60～80 ml/min,采血同时静脉输注与采血等速率的6%羟乙基淀粉130/0.4.采集的自体血经2个循环的直接法分离为富含血小板血浆、贫血小板血浆和浓缩红细胞,每个循环以分离出红细胞后15 s时停止采血.出血量≥全身血容量的20%时立即回输自体血;出血量<全身血容量20%者,在缝合子宫后回输,依次回输富含血小板血浆、输贫血小板血浆和输浓缩红细胞.监测母体生命体征指标和胎儿心率.记录自体血采集过程中低血压和心动过速的发生情况.分别于采血前(基础状态)、采血结束时、自体血回输前和术后24 h时采集外周静脉血样,测定Hb、Hct、Plt、PT、APTT、INR和Fib.胎儿娩出后采集脐动脉血样,进行血气分析.于胎儿娩出后1、5min时行Apgar评分.记录术中出血量和异体输血情况.结果 自体血采集过程中未见低血压和心动过速的发生,胎儿HR维持在正常范围.与基础状态比较,其他时点SpO2、Hb、Hct、Plt、PT、APTT、INR和Fib差异无统计学意义(P>0.05).脐动脉血pH值、BE和乳酸浓度均在正常范围内.胎儿娩出后1、5 min时Apgar评分分别为(9.0±0.8)、(9.2±0.8)分;术中出血量(405±28)ml,所有病人未输注异体血.结论 Rh(D)阴性血型病人剖宫产术中成分式自体输血的安全性良好.

Abstract：

Objective To investigate the safety of autologous blood component transfusion during cesarean section in patients with Rh (D)-negative blood group.Methods Thirty ASA Ⅰ or Ⅱ patients of Rh (D)-negative blood group, aged 20-35 yr, weighing 50-80 kg, undergoing elective cesarean section, were enrolled in this study.After lactated Ringer' s solution 7 ml/kg was infused, blood was obtained from radial artery at a rate of 60-80ml/min, and blood volume was maintained by simultaneous infusion of 6% hydroxyethyl starch 130/0.4 at the same rate. The collected blood was subjected to two cycles of autologous blood component separation. Blood collecting during each cycle was stopped 15 s after red blood cells were separated. The autologous blood was infused when the blood loss≥20% of blood volume. The autologous blood was infused after suture of the uterus when the blood loss < 20% of blood volume. The parameters of maternal vital signs and fetal heart rate were monitored. Hypotension and tachycardia were recorded during autologous blood collecting. SpO2 was monitored routinely. Venous blood samples were taken before blood collecting (baseline), at the end of blood collecting, before autologous blood transfusion, 24 h after operation for determination of Hb, Hct, Plt, PT, APTT, INR and Fib. Umbilical arterial blood samples were obtained after delivery for blood gas analysis. Apgar score was recorded at 1 and 5 min after birth. Blood loss and allogeneic blood transfusion were also recorded. Results No hypotension and tachycardia occurred during the process of blood collecting and the fetal heart rate was within the normal range. Compared with the baseline value, there were no significant differences in SpO2 , Hb, Hct, Plt, PT, APTT, INR and FIB value at the other time points. The pH value and concentrations of base excess and lactate were within the normal range.The Apgar score was (9.0 ±0.8) and (9.2 ± 0.8) at 1 and 5 min after birth respectively. The blood loss during operation was (405 ± 28) ml and no patients received homologous blood transfusion. Conclusion The safety of autologous blood component transfusion is good during cesarean section in Rh (D)-negative blood group patients.     

骨科手术患者急性高容量血液稀释-止血药-自体血回收联合应用的血液保护效果

目的 评价骨科手术患者急性高容量血液稀释(AHH)-止血药-自体血回收(IOBS)的血液保护效果.方法 择期骨科手术患者120例,性别不限,年龄18～64岁,ASA Ⅰ或Ⅱ级,预计术中出血量>800 ml,随机分为4组(n=30):AHH-IOBS-止血药组、IOBS-止血药组、 IOBS组和AHH-止血药组.AHH:气管插管后即刻至切皮前即刻,静脉输注6%羟乙基淀粉130/0.4溶液15 ml/kg,速率40 ml/min;IOBS:切皮前即刻行血液回收,血液洗出后即刻回输;止血药:切皮前10 min静脉注射血凝酶2 kU,同时肌肉注射1 kU.记录术中液体出入量、心率(HR)、平均动脉压(MAP)和中心静脉压(CVP),并采集静脉血样检测下列指标:血红蛋白浓度(Hb)、红细胞压积(Hct)、血小板计数(Plt)、凝血酶原时间(PT)、活化部分凝血酶原时间(APTT)和纤维蛋白原浓度(Fib).结果 与AHH-IOBS-止血药组比较,IOBS-止血药组CVP降低,Hb、Hct、Plt和Fib升高,AHH-IOBS组术中出血量增多,AHH-止血药组异体输血量增多和新鲜冰冻血浆使用免除率和异体输血免除率降低(P<0.05或0.01).结论 骨科手术患者AHH-IOBS-止血-联合应用的血液保护效应较好,安全性高.     

血液回收技术在骨科大手术中的应用

目的：观察血液回收技术在骨科大手术中应用的作用。方法：40例择期行骨科手术病人配对后随机分为两组,自体血回收组用血液回收仪回收术中失血,对照组不回收失血,分别采术前,术毕后3小时,术后第1天及术后第7天的静脉血,测定红细胞计数（RBC）,血红蛋白（Hb),血细胞压积（Hct),血小板计数（Pt),出血时间（BT）,凝血时间（CT）,凝血酶源时间（PT）,血陶土部分凝血活酶时间（KPTT）,凝血酶时间（TT）,结果：两组病人异体血输用量有显著差异（P＜0．01）,自体血回收组术后第1天引流量明显少于对照组（P＜0．01）,其RBC,Hb于术后第1天均高于对照组（P＜0．05）,术毕及术后第7天后两组差别不明显（P＞0．05）,两组Pt和Hct在各测定时点无明显差别（P＞0．05）,自体血回收组术毕的KPTT明显延长（P＜0．05）,对照组PT,TT,KPTT均明显延长（P＜0．05）,两组病人各测定时点BT,CT均在正常范围,结论：全自动血液回收技术明显减少异体血用量,可安全用于骨科手术。     

急性等容血液稀释结合术中自体血回输在脊柱手术中的应用

目的 探讨急性等容血液稀释结合术中自体血回输在脊柱手术中临床应用的可行性。方法 38例腰椎滑脱行后路减压、椎弓根螺钉内固定加椎体间Cage融合术患者,随机分为三组,急性等容血液稀释结合术中自体血回输组(组Ⅰ,n=12);自体血回输组(组Ⅱ,n=12);对照组(组Ⅲ,n=14)。术中均采用控制性低血压,记录术前、术中、回输前、回输后、术后的血红蛋白和红细胞比容,分别记录回输的血量和输异体血量。结果 急性等容血液稀释结合术中自体血回输组术中输异体血量约100ml,自体血回输组输异体血量约400ml,对照组输异体血量约800ml,经统计学检验有显著差异(P<0.05)。结论急性等容血液稀释结合术中自体血回输在脊柱手术中临床应用是一种安全有效、节约血源的方法,可减少异体血输入,避免其并发症。     

不同种类液体急性等容血液稀释对脊柱手术患者血流动力学的影响和血液保护效应

目的观察不同种类液体急性等容血液稀释(ANH)对脊柱手术患者血流动力学的影响和血液保护效应。方法选择择期全麻下行后路脊柱手术的患者60例,男30例,女30例,年龄48~65岁,ASAⅠ或Ⅱ级,随机分为三组:ANH晶体组(A组)、ANH胶体组(B组)和对照组(C组),每组20例。A组和B组在俯卧位全麻下行ANH,目标Hct为32%,A组放血同时用3倍体积的复方乳酸钠稀释,B组放血同时用相同体积的羟乙基淀粉130/0.4氯化钠注射液稀释,C组不做ANH,为对照组。记录ANH前5 min(俯卧位后5 min,T0)、ANH结束后10 min(切皮前5 min,T1)、输血(包括异体血和自体血)前5min(T2)和输血结束后10min(T3)的MAP、HR、心脏指数(CI)、每搏量变异度(SVV)、Hb、Hct、Plt、凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)及BIS和体温;监测三组术中出血量、输血量(包括悬浮红细胞、血小板和新鲜冰冻血浆)、输注异体血患者例数、输液量及尿量。结果 T2、T3时A组MAP明显低于,SVV明显高于T0时和B、C组(P0.05);T1时A、B组CI明显高于T0时和C组(P0.05),T2、T3时B、C组CI明显高于T0时和A组(P0.05);T1、T3时A、B组Hb、Hct及Plt明显低于T0时(P0.05);T1、T2时A、B组Hb、Hct及Plt明显低于C组,T3时明显高于C组(P0.05);T2、T3时三组PT及APTT明显长于T0时,T3时A、B组PT及APTT明显短于C组(P0.05)。A、B组术中未输入悬浮红细胞,输入悬浮红细胞及输注异体血患者例数明显少于C组(P0.05);A组晶体液输入量明显多于B、C组,B组明显少于C组(P0.05);A、C组胶体液输入量明显少于B组(P0.05);A组尿量明显多于B、C组(P0.05)。三组术中出血量差异无统计学意义。结论 ANH可减少脊柱手术患者术中异体悬浮红细胞的输入量,有利于凝血功能的恢复,具有明显的血液保护效应;胶体液行ANH的扩容效果优于晶体液。     

肝移植术中大量输血的影响因素分析及预测模型构建

目的探讨肝脏移植术中大量输血的影响因素,并建立大量输血的预测模型。方法回顾性分析南京大学医学院附属鼓楼医院2018年度肝脏外科同一肝移植小组进行的103例肝移植受者资料,根据受者术中红细胞输注量分为大量输血组(≥12 U)40例和非大量输血组(<12 U)63例,比较分析两组受者的一般情况和术前指标,用Logistic回归分析法得出肝移植术中大量输血的预测模型。结果大量输血组和非大量输血组在性别、年龄、血型等方面差异无统计学意义(P>0.05),而术前诊断、血红蛋白(Hb)、血细胞比容(HCT)、血小板计数(PLT)、国际标准化比值(INR)、凝血酶原时间(PT)、部分活化凝血活酶时间(APTT)、凝血酶时间(TT)、血清总胆红素(TBIL)、血清直接胆红素(DBIL)、终末期肝病模型(MELD)评分等指标与术中大量输血存在相关性(P<0.05)。通过Logistic回归分析,得出肝移植术中大量输血的预测模型为Y=3.545-0.112×HCT-0.009×PLT+0.005×DBIL。其预测值经受试者操作特征曲线曲线分析得出曲线下面积为0.813,灵敏度和特异度分别为80.0%和71.4%,约登指数(Youden's index)为0.514,即Y≥0.514时则可能发生术中大量输血。结论肝移植受者术前HCT、PLT和DBIL可以作为术中大量输血的独立预测因素,其预测模型有较好的灵敏度和特异度。     

Cost analysis of intraoperative blood salvage during orthotopic liver transplantation

Approximately 6,000 to 7,000 orthotopic liver transplantation (OLT) procedures are performed annually, which require the administration of large volumes of blood products. Thus liver transplantation can significantly strain local and regional blood resources at a time when transfusion practices are changing dramatically, in large part because of anxiety caused by the human immunodeficiency virus. Intraoperative autologous transfusion has been proposed as a means of both reducing transfusion demands and lessening the hazards of allogeneic transfusion. However, the cost effectiveness of intraoperative blood salvage has not been unequivocally determined. We retrospectively examined the cost of intraoperative autologous transfusion during OLT for a 2-year period at the University of Cincinnati Hospital. A direct comparison was made between the charge for autologous transfusion and the calculated cost of allogeneic transfusion. Seventy OLT procedures were performed during the years 1993-1994. The average charge for autologous transfusion was $1,048.73 per case. Cell-salvage volumes for all cases were added, and the calculated conservation of allogeneic packed red blood cells totaled 359.6 units, worth $30,026.60 or $428.95 per case. The break-even point is approximately 12.6 units, and most patient do not receive this volume of salvaged blood. In fact, cell salvage reached cost equivalence in only three cases (4.8%). Moreover, the cost deficit of autologous transfusion during this 2-year period averaged $586.56 per case. (Liver Transpl Surg 1997 Sep;3(5):513-7)     

Blood-transfusion requirements and blood salvage in donors undergoing right hepatectomy for living related liver transplantation

Living related liver donation for liver transplantation in adults including its risks is receiving increased attention. We present data from 44 liver donors focusing on transfusion requirements and avoidance of heterologous transfusion. The volume of blood transfused (both autologous from preoperative donation and heterologous) was assessed including that derived from intraoperative isovolemic hemodilution, cell-saver salvaged, and retransfused blood. Hemoglobin concentration and central venous pressure were measured at specified time points before and during surgery. Intraoperative blood loss was calculated and correlated to the duration of parenchymal transsection, liver volume resected, and central venous pressure. There were no specific anesthesia-evoked complications. In 4 donors, major bleeding (>2000 mL) occurred. Blood loss averaged 902 +/- 564 mL (SD), yielding a minimal mean hemoglobin concentration of 8.1 +/- 1.2 g/dL. One donor received 3 U of heterologous blood and 30 donors received autologous blood from their preoperative donation. An average of 592 +/- 112 mL of blood derived from perioperative acute isovolemic hemodilution was retransfused as was 421 +/- 333 mL of washed red cells from the cell-saving system. Avoidance of heterologous blood transfusion, application of blood-saving techniques, and efficient pain management are crucial for adult living liver donors. Transfusion of banked blood can be avoided in most patients when intraoperative cell salvage, preoperative autologous blood donation, and intraoperative hemodilution are combined.     

A prospective study investigating the cost effectiveness of intraoperative blood salvage during liver transplantation

BACKGROUND: Adult orthotopic liver transplantation is associated with significant use of allogenic blood products, which places considerable demands on finite resources. This could be reduced by autologous red cell salvage use, and we evaluated its cost effectiveness in this prospective study. METHODS: Intraoperative autotransfusion was used in 660 adult liver transplant patients between January 1997 and July 2002. These included 134 with acute liver failure, 62 retransplants, 90 alcohol-related, 183 viral, 98 cholestatic chronic liver diseases, and 93 with other etiologies. RESULTS: The total volume of red blood cells transfused was 3641+/-315 ml, 2805+/-234 ml, 2603+/-443 ml, and 2785+/-337 ml for alcohol-related, viral, cholestatic, and others, respectively. Low preoperative hemoglobin was significantly associated with higher intraoperative transfusion requirements. Blood volumes transfused at retransplantation were significantly higher (7077+/-1110 ml vs. 2864+/-138 ml; P<0.001) than for acute liver failure and chronic liver disease. Autologous blood volumes transfused were similar in all diagnostic groups, but were significantly greater in retransplantation (2754+/-541 ml vs. 1524+/-77 ml; P<0.01). Venovenous bypass was significantly associated with higher transfusion requirements. Total savings per case were similar for all diagnostic groups but were greater in cases of retransplantation (864+/-222 pounds (1235+/-317 US dollars) vs. 238+/-24 pounds (340+/-34 US dollars; P<0.001). With the use of autologous transfusion over the study period, a cost saving of 131,901 pounds (188,618 US dollars) was achieved. CONCLUSIONS: Intraoperative red blood cell salvage and autologous transfusion is cost effective in adult liver transplantation. Currently, where optimum resource utilization and fiscal constraint are paramount in healthcare delivery, autologous transfusion is an important adjunct in liver transplantation.     

Intraoperative blood transfusion requirement is the main determinant of early surgical re-intervention after orthotopic liver transplantation

Liver transplantation is the treatment of choice in selected patients with end-stage liver disease. Postoperative complications often require surgical re-intervention. This study is a retrospective single-centre study to assess the incidence and type of surgical re-intervention during the in-hospital period after liver transplantation and to identify predictors of this re-intervention. From 1994 to 2002, 231 consecutive adult liver transplantations were performed. Re-intervention was classified as biliary, vascular, bleeding, septicaemia, re-transplantation or as miscellaneous. One hundred and thirty-nine surgical re-interventions were performed in 79 of 231 patients (34%). Septicaemia (44%) and bleeding (27%) were the most frequent indications for re-intervention, followed by biliary (10%) re-intervention. Vascular re-intervention, re-transplantation, and re-intervention for miscellaneous reasons, were performed in 7% each. Of all analysed variables (gender, age, diagnosis, acute liver failure, Child–Pugh classification, Karnofsky score, previous abdominal surgery, creatinine clearance, prothrombin time, anti-thrombin, platelet count, surgical technique, cold ischaemia time, warm ischaemia time, functional anhepatic time, anatomic anhepatic time, revascularisation time, year of transplantation, aprotinin administration, transfused platelet concentrate, and red blood cell transfusion requirements), only the number of transfused red blood cell concentrates (RBCs) was identified as a predictor of surgical re-intervention. Median RBC transfusion requirement during liver transplantation was 2.9 l (range 0–18.8 l) in the re-intervention group compared with 1.5 l (range 0–13.4 l) in the non-re-intervention group (P<0.001). This study revealed intraoperative blood loss as the main determinant of early surgical re-intervention after liver transplantation and emphasises the need for further attempts to control blood loss during liver transplantation.     

终末期肝病模型评分较高的良性终末期肝病患者肝移植疗效评价

目的 探讨终末期肝病模型(MELD)评分较高的良性终末期肝病患者的肝移植疗效.方法 回顾分析80例良性终末期肝病肝移植患者的资料,根据MELD评分的不同将患者分成两组,MELD评分≥30分的23例为高MELD评分组,MELD评分＜30分的57例为低MELD评分组.分别比较两组患者手术时间、术中无肝期、术中血液制品输入量、术后重症监护病房(ICU)治疗时间和受者1年存活率,同时比较死亡患者和存活患者的临床资料,寻找导致术后死亡的危险因素.结果 高MELD评分组的手术时间、术中血液制品输入量、ICU治疗时间以及术后3个月内的死亡率明显高于低MELD评分组,差异有统计学意义(P＜0.05),而术中无肝期和患者1年存活率,两组间的差异无统计学意义(P＞0.05).死亡者和存活者相比较,MELD评分的差异无统计学意义(P＞0.05),而术前机械通气、血清钠水平、持续性肝性脑病(重型)等方面的差异有统计学意义(P＜0.05).结论 对于良性终末期肝病患者,单纯依靠MELD评分不足以准确判断患者肝移植术后的生存状态,高MELD评分者也可获得较好的肝移植结果,术前严重的低钠血症、重度肝性脑病以及机械通气是除MELD评分以外影响患者术后生存状况的危险因素.     

Poor prediction of blood transfusion requirements in adult liver transplantations from preoperative variables

STUDY OBJECTIVE: To assess the ability of preoperative information to predict intraoperative blood transfusion requirements in adult orthotopic liver transplantation. DESIGN: Retrospective review. SETTING: Liver transplantation program in a referral center. PATIENTS: 583 sequential adult patients undergoing orthotopic liver transplantation. MEASUREMENTS: Preoperative variables with a previously demonstrated relationship to intraoperative transfusion were identified from the literature. These variables were then collected retrospectively from 583 consecutive liver transplantations. Relationships between these and intraoperative blood transfusion requirements were examined by both univariate analyses and multiple linear regression analysis. RESULTS: Univariate analysis revealed significant associations between blood transfused and the following preoperative variables: age, gender, diagnosis, presence of grade 3 or 4 encephalopathy, pseudocholinesterase, creatinine, bilirubin, mean pulmonary artery pressure, activated partial thromboplastin time, and platelet count. Multiple linear regression analysis with correction for diagnosis identified age, creatinine, bilirubin, and pseudocholinesterase as independent predictors; for the final model r(2) = 0.22. CONCLUSION: Preoperative variables are poor predictors of intraoperative transfusion requirements even when significant associations exist, identifying a small proportion of the variability observed. A predictive approach based on this method would be too inaccurate to be of clinical use. The majority of the variability in transfusion requirements during liver transplantation most likely results from intraoperative and donor organ factors.     

Intraoperative blood transfusion requirement is the main determinant of early surgical re-intervention after orthotopic liver transplantation

Abstract Liver transplantation is the treatment of choice in selected patients with end‐stage liver disease. Postoperative complications often require surgical re‐intervention. This study is a retrospective single‐centre study to assess the incidence and type of surgical re‐intervention during the in‐hospital period after liver transplantation and to identify predictors of this re‐intervention. From 1994 to 2002, 231 consecutive adult liver transplantations were performed. Re‐intervention was classified as biliary, vascular, bleeding, septicaemia, re‐transplantation or as miscellaneous. One hundred and thirty‐nine surgical re‐interventions were performed in 79 of 231 patients (34%). Septicaemia (44%) and‘bleeding (27%) were the most frequent indications for re‐intervention, followed by biliary (10%) re‐intervention. Vascular re‐intervention, re‐transplantation, and re‐intervention for miscellaneous reasons, were performed in 7% each. Of all analysed variables (gender, age, diagnosis, acute liver failure, Child‐Pugh classification, Karnofsky score, previous abdominal surgery, creatinine clearance, prothrombin time, anti‐thrombin, platelet count, surgical technique, cold ischaemia time, warm ischaemia time, functional anhepatic time, anatomic an‐hepatic time, revascularisation time, year of transplantation, aprotinin administration, transfused platelet concentrate, and red blood cell transfusion requirements), only the number of transfused red blood cell concentrates (RBCs) was identified as a predictor of surgical re‐intervention. Median RBC transfusion requirement during liver transplantation was 2.9 1 (range 0–18.8 1) in the re‐intervention group compared with 1.5 1 (range 0–13.4 1) in the non‐re‐intervention group (P< 0.001). This study revealed in‐traoperative blood loss as the main determinant of early surgical re‐intervention after liver transplantation and emphasises the need for further attempts to control blood loss during liver transplantation.     

Cell Salvage During Liver Transplantation for Hepatocellular Carcinoma: A Retrospective Analysis of Tumor Recurrence Following Irradiation of the Salvaged Blood

BackgroundOrthotopic liver transplantation (OLT) is the treatment option for early-stage hepatocellular carcinoma (HCC). OLT is often associated with high blood loss, requiring blood transfusion. Retransfusion of autologous blood is a key part of blood conservation. There are, however, concerns that the retransfusion of salvaged blood might cause the spread of cancer cells and induce metastasis. Irradiation of salvaged blood before retransfusion eliminates viable cancer cells. Here, we analyzed the incidence of tumor recurrence in patients with HCC undergoing OLT who received irradiated cell-salvaged blood during transplant surgery.MethodsWe retrospectively analyzed patients undergoing OLT for HCC between 2002 and 2018 at our center. We compared the tumour recurrence in patients who received no retransfusion of autologous blood with patients who received autologous blood with or without preceding irradiation of the blood.ResultsFifty-one (40 male, 11 female) patients were included in the analysis; 10 patients developed tumor recurrence within a time period of 2.45 ± 2.0 years. Statistical analysis revealed that there was no significant difference in tumor recurrence between patients who received autologous blood with or without irradiation.ConclusionIntraoperative transfusion of cell-salvaged blood did not increase tumor recurrence rates. Cell salvage should be used in liver transplantation of HCC patients as part of a blood conservation strategy. The effect of blood irradiation on tumor recurrence could not be definitively evaluated.     

难治性复发肝肿瘤的肝移植

目的探讨难治性复发肝肿瘤行肝移植的难点及围手术期处理注意事项。方法总结2003年9月至2004年9月我科施行的14例肝移植，其中难治性复发肝肿瘤9例（A组），其余5例术前未接受任何有创治疗（B组），分析两组术前治疗情况、术中探查情况、病肝游离时间、无肝期时间、术中出血、输血及止血药物使用情况、手术死亡率、术后肾上腺糖皮质激素的减撤及化疗等情况。结果A组术中病肝游离时间、无肝期时间明显较B组长，出血、输血量及止血药物的用量均明显大于B组，手术死亡2例均为A组病例。术后存活的肝癌病例均行全身化疗，肾上腺糖皮质激素于3个月内停药，至今均无瘤生存。结论难治性复发肝肿瘤的肝移植较一般肝移植手术难度大，对术者要求更高，术中监护和补充凝血因子极为重要。围手术期抗肿瘤治疗、术后尽早减撤肾上腺糖皮质激素对术后无瘤生存有积极意义。