张循善输血治疗传统观念的变革与更新XXXX省医学会

1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2主要内容询证输血医学新观念现代输血疗法的临床应用3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4CritCareMed2009Vol.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5败血症患者要求较高Hb水平的适应证不包括支持目的ConditionsinsepticpatientsthatmayrequireahigherhemoglobinAcuteinstabilityCardiovasculardiseaseCoronaryarterydiseaseLowcardiacoutputPulmonarydiseaseSeverearterialhypoxemiaOrganortissueischemiaSeveremixedvenousdesaturation（混合静脉血氧饱和度，过低表明组织氧合障碍）ElevatedlactatelevelUseofbloodproductsinsepsis:Anevidence-basedreview.CritCareMed2004;32(Suppl):S542–S547.6FFP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–S547.7重症患者输注红细胞导致的不良转归From571articlesscreened,45metinclusioncriteriaIn42ofthe45studiestherisksofRBCtransfusionoutweighedthebenefits;Seventeenof18studies,demonstratedthatRBCtransfusionswereanindependentpredictorofdeath;Twenty-twostudiesexaminedtheassociationbetweenRBCtransfusionandnosocomialinfection;inallthesestudiesbloodtransfusionwasanindependentriskfactorforinfection.RBCtransfusionssimilarlyincreasedtheriskofdevelopingmulti-organdysfunctionsyndrome(threestudies)andacuterespiratorydistresssyndrome(sixstudies).MarikPE,CorwinHL.Efficacyofredbloodcelltransfusioninthecriticallyill:asystematicreviewoftheliterature[J].CritCareMed.2008;36(9):2667-26748相对危险度腹腔间隙综合征91011Prospective,multiplecenter,observationalcohortstudy（观测队列研究）of4,892ICUptsintheUSPropensityscore（倾向指数）matchedDesignedtoexaminetherelationshipofanemiaandRBCtransfusionwithclinicaloutcomesAlmost95%ofpatientsadmittedtotheICUhaveaHblevelbelow“normal”byday3Intotal,11,391RBCunitsweretransfused.Overall,44%ofptsadmittedtotheICUreceivedoneormoreRBCunitswhileintheICUCritCareMed.2004Jan;32(1):39-5212Themeanpre-transfusionHbwas8.6±1.7g/dLRBCtransfusionwasindependentlyassociatedwithhighermortality(OR1.65CI1.35-2.03).OR2.62if3-4unitstransfusedp0.000135%ofBloodtransfusedinpatientswithHgb9CritCareMed.2004Jan;32(1):39-5213Analysisof24,112enrolleesin3largeinternationaltrialsofpatientswithacutecoronarysyndromesAssociationbetweentransfusionandoutcomeCoxproportionalhazardsmodelingMainoutcome=30daymortalityRaoSVetal.JAMA.2004;292:1555-156214BloodTransfusionandClinicalOutcomeinAcuteCoronarySyndromeRaoSVetal.JAMA.2004;292:1555-1562TransfusionNoTransfusionAdjustedhazardratio3.94(3.26-4.75)15研究对象研究结论16老年退伍军人局171815,592CardiovascularoperationsInfectionendpointsbacteremia,SSI55%ofptsreceivedPRBCs,21%plts,13%FFP,3%cryoprecipitateIncreasedRBCtxassociatedwithincreasedinfection(p0.0001),confirmedbylogisticregressionanalysis.JAmCollSurg2006;202:131-13819EffectofBloodTransfusiononLong-TermSurvivalAfterCardiacOperation1915CABGptsAftercorrectionforcomorbiditiesandotherfactors,txwasstillassociatedwitha70%increaseinmortality(RR1.7;95%CI1.4to2.0;p0.001).EngorenMCetal.(MCO,Toledo)AnnThoracSurg2002;74:1180–620患者输注红细胞导致的不良转归机制Storagelesion库存红细胞2.3-DPG含量下降MetabolicacidosisAlteredoxygencarryingcapacity库存红细胞变形能力下降库存红细胞携带NO能力减弱Increasedredcelldeathwithincreasedageofblood(~30%dead)Noimprovementinoxygenutilizationatthetissuelevel同种输血的免疫负向调节作用212223研究结果Themediandurationofstoragewas11daysfornewerbloodand20daysforolderblood.Patientswhoweregivenolderunitshadhigherratesofin-hospitalmortality(2.8%vs.1.7%,P=0.004),intubationbeyond72hours(9.7%vs.5.6%,P0.001),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%,P0.001).24ImmuneEffectsofBloodImmunologiceffectsofallogenicbloodTxDecreasedT-cellproliferationDecreasedCD3,CD4,CD8T-cellsIncreasedsolublecytokinereceptorsTNF-R,sIL-2RIncreasedsuppressorT-cellactivityReducednaturalkillercellactivityMcAlisterFAetal,BrJSurg1998;85:171-8.InnerhoferPetal,Transfusion1999;39:1089-96.25输血不能促进伤口愈合26手术切口愈合紊乱诊断标准结果和机制27underwentlaparotomy（剖腹术）underwentgastrectomy（胃切除）underwentgastroduodenostomy（胃十二指肠吻合术）CONCLUSIONS:Bloodtransfusionsincreasedtheincidenceofanastomoticabscess（脓肿）andimpairedanastomoticwoundhealing.282001andJune2005wehaveperformedaprospectiveobservationalstudyin1553electiveandemergencypatientswhounderwentmediansternotomyforheartsurgery.CONCLUSIONS:Accordingtoourresults,thetotalamountofallogeneicbloodtransfusedisamajorfactorcontributingtosternaldehiscence（胸骨裂开）regardlessofotherriskpreconditions