首都医科大学北京友谊医院xx科 田鸣2009.9.8 北京
输血存在的两大问题
血源性传染病和输血反应 我国乙肝病毒(HBV)感染人数达1.1亿,占总人口9%;90%丙肝由输血传播,输血后丙肝发病率高达10%-20%,特殊人群中丙肝病毒(HCV)携带者达70%;我国HIV感染者已超过84万,实际数?血源不足与滥用 我国年用血量超过1300吨,其中外科用血约占70%,临床不必要的输血占50%.
输血原则
安全、有效、节约
围术期输血Perioperative Transfusion Medicine
Non-Transfusion MethodsHemostasis (Surgical / Medicine)Transfusion TriggerIndications for Blood TransfusionAutotransfusionPreoperative Autologous Donation (PAD)Acute Normovolemic Hemodilution (ANH) Intraoperative Autologous DonationRed Cell Salvage (CS)Minimize Allogeneic Transfusion
过去二十年临床输血的改变Changes in red blood cell transfusion practice during the past two decades
A retrospective analysis, with the Mayo database, of adult patients undergoing major spine surgery1980 to 1985 early practice group; n = 6991995 to 2000 late practice group; n = 610Compared to the early practice group:所有术前的 Hb 浓度显著降低异体 RBC 输入显著减少,而自体输血明显增加no significant difference in major morbidity or mortality was observed between groups
Wass CT, Transfusion. 2007;47(6):1022 USA
无血外科的概念
1. 不输血
2. 自体输血
3. 成分输血(异体)
术前准备、手术技术
xx、输血科管理
医院多处室协调
目的:减少异体输血
掌握输血指征
Transfusion Trigger:必须开始输血的时机:Hb/Hct 和 综合判断10/30 rules: Hb=10g/dl;Hct=30 % 一般情况下,达到了这个标准就不必继续输血出手术室、出院时Overtransfusion: 在任何时候当输血使得 Hct≥36% 时,就认为是过度输血
失血后不输血的手术死亡率 术前Hb水平 死亡率(%)
Carson [1988]
Hb Transfusion Trigger US
6g/dl:<50岁,无心脏病和术后并发症 8g/dl:稳定性的心脏病,失血300ml10g/dl:老年人,术后有并发症,心肺代偿差Robertie:Int Anesthesiol Clin 28:197-204,199011g/dl(Hct33%):重危病人,强调维持适当的血容量比输血更重要Czer and Shoemaker:Optimal hematocrit value in critically ill postoperative patients. Surg Gynecol Obstet 147: 363-368,1978
卫生部输 血指南(2000年)
Hb > 100g/L 不必输血 Hb < 70g /L 应考虑输入浓缩红细胞 Hb 70~100g/L 根据病人代偿能力、一般情况和其它脏器器质性病变
出手术室的Hb/Hct标准
Hb 8-9g/dl;Hct 25-27%ASA Status ⅠⅡ, 年青Hb 9-10g/dl;Hct 28-30%ASA Status ⅢHb 11-12g/dl;Hct 33-35%ASA Status Ⅳ Ⅴ,老年人 Hb > 12g/dl; Hct >36% Overtransfusion 过度输血
Recommendation that procedure or treatment not useful/effective and may be harmful Only expert opinion, case studies, or standard-of-care
Recommendation\’s usefulness/efficacy less well established Only diverging expert opinion, case studies, or standard-of-care
Recommendation in favor of treatment or procedure being useful/effectiveOnly diverging expert opinion, case studies, or standard-of-care
Recommendation that procedure or treatment is useful/effectiveOnly expert opinion, case studies, or standard-of-care
Level C 极有限 (1-2)人群的风险评估
Recommendation that procedure or treatment not useful/effective and may be harmfulLimited evidence from single randomized trial or non-randomized studies
Recommendation\’s usefulness/efficacy less well established Greater conflicting evidence from single randomized trial or non-randomized studies
Recommendation in favor of treatment or procedure being useful/effectiveSome conflicting evidence from single randomized trial or non-randomized studies
Recommendation that procedure or treatment is useful/effectiveLimited evidence from single randomized trial or non-randomized studies
Level B 有限 (2-3)人群的风险评估
Recommendation that procedure or treatment not useful/effective and may be harmful Sufficient evidence from multiple randomized trials or meta-analyses
Recommendation\’s usefulness/efficacy less well established Greater conflicting evidence from multiple randomized trials or meta-analyses
Recommendation in favor of treatment or procedure being useful/effective Some conflicting evidence from multiple randomized trials or meta-analyses
Recommendation that procedure or treatment is useful/effective Sufficient evidence from multiple randomized trials or meta-analyses
Level A 多个 (3-5)人群的风险评估;一致的认识方向和明显的疗效.
Risk ≥ Benefitxx不应当执行因为无益或有害
Benefit >> Riskxx没有理由不执行需要补充广泛的研究
Benefit >> Riskxx有理由执行需要补充特定的研究
Benefit >>> Riskxx应当执行
证据水平
Class III
Class IIb
Class IIa
Class I
推荐类别
Classification Scheme Used to Summarize of Clinical Recommendations
Transfusion Triggers
Class IIaWith Hb< 6 g/dL, RBC transfusion is reasonable, as this can be lifesaving. Transfusion is reasonable in most postoperative patients whose Hb<7 g/dL, but no high-level evidence supports this recommendation. (Level of evidence C)Class IIbIt is not unreasonable to transfuse red cells in certain patients with critical noncardiac end-organ ischemia (eg, central nervous system and gut) whose Hb>=10 g/dL, but more evidence to support this recommendation is required. (Level of evidence C)Class IIITransfusion is unlikely to improve oxygen transport when Hb>10 g/dL and is not recommended. (Level of evidence C)
综合判断输血指征
综合分析,因人而异贫血持续的时间,血管内的容积手术的范围,大出血的可能性存在的合并症:如肺功能障碍,心输出量下降,心肌缺血,脑血管或外周循环疾病.综合判断:术中通过对术野的观察结合血标本的结果,对心肺功能的监测综合判断出每一病人所能接受的{zd1}Hb值.Consensus Conference: Red Blood Cell Transfusion. JAMA, 1998, 260: 2700-2703
取库血前是否测 Hb/Hct ?
原则上应当测得 Hb/Hct 后再决定是否输血(取血)大多数(> 90%),常规都要执行但不{jd1},结合临床(< 10%)对Hb/Hct 和血容量的变化心中有数反复测量 Hb/Hct 和 估计失血量和血容量避免毫不知情的盲目输血
常规每次取血两个单位
一次应当只取两个单位的血(>90%)在输血中或随后评估效果及进一步的需要量减少误判,节约血源和病人负担某些例外是可能的 (< 10%)
围产期患者输入红细胞的合理性The appropriateness of red blood cell transfusions in the peripartum patient
1994 ~ 2002218/33,795 obstetrics-related (0.65% of all admissions), an RBC transfusion was given There were 83 vaginal deliveries, 94 deliveries by cesarean, and 42 other operationsA total of 779 RBC units were transfused, median, 2 units per womanmost commonly for postpartum bleeding (34% of cases). 16 adverse events from transfusion recorded.按照指南的标准,输入的 248 个单位的 RBC (32%) 是不合适的!
Obstet Gynecol. 2004;104(5 Pt 1):1000 Canada
提高自体输血的比例
管理指标:自体输血的比例应>20%措施:提高自体血应用量降低库血的应用量
围术期自体输血的种类
储存式 术前自体献血( Preoperative Autologous Donation PAD)急性等容稀释(Acute Normovolemic Hemodilution ANH) (Intraoperative Autologous Donation)急性高容稀释(Acute Hypervolemic Hemodilution AHH)回收式(Blood Salvage BS)术中对自体血回收及回输术后对自体血回收及回输
应当{sx}自体血
避免血源传播性疾病避免输血的免疫反应降低对库血的需要量已备好或及时回收自体血,有利于挽救血液质量高功能好
术前自体献血Preoperative Autologous Donation PAD
择期手术患者一般情况较好,Hb大于110g/L预计术中出血量超过循环血量15%稀有血型、配血困难;宗教信仰无心、肺、肾功能障碍无造血功能、凝血功能障碍无菌血症
术前需多次采血,给病人带来不便可降低患者术前 Hb程序复杂,需要血库储存有成分的损耗(凝血因子等)血液保存时间有限,无法交互使用过期浪费的可能(50%),增加了费用采血和保存期有xx污染的可能
PAD 缺点 -不常用
急性等容稀释 (acute normovolemic hemodilution ANH)
ANH-常用是有效和最经济的自体输血方法可以直接采集全血,也可通过专用设备单采红细胞采血的同时等量输入非细胞溶液(胶体或晶体液)室温保存,在手术室内输入Monk TG, Goodnough LT: Acute normovolemic hemodilution. Clin Orthop, 1998, 357:74-81
血液稀释技术
血液黏度的降低
外周血管阻力的下降
心输出量增加
微循环改善
组织氧摄取量的增加
血红蛋白-氧亲和力降低
血液稀释
代偿血氧含量降低维持组织氧供
病理生理学效应
血液稀释技术
Gross 公式
计算边采血边输液病人的采血量术前采血量(L) (采血前Hct -目标Hct) (采血前Hct+目标Hct)Gross JB: Estimating allowable blood loss: Corrected for dilution. Anesthesiology, 1983, 56: 577-580VL= EBV*(HctO-HctF)/Hctave
= 7%体重(kg)*2
ANH 的方法
xx后手术前采集自身血同时输入等量胶体液或3倍晶体液或不同比例的晶胶混合液稀释过程中保持血容量基本恒定术中血液有形成分丢失减少术终再将自体血反顺序回输
Prospective RCT of ANH in major gastrointestinal surgery
Aim : to assess the effects of ANH on allogeneic transfusion3unit-\’ANH\’ n=78, \’no ANH\’ n=82fewer patients in the ANH group experienced oliguria in the immediate postoperative period37/78 (47%) vs 55/82 (67%) (P=0.012).ANH 并不改变异体输血率术前 Hb 水平、术中失血量和输血规程是影响异体输血的关键因素compared with ASA-matched historical controls , the introduction of a transfusion protocol reduced the transfusion rate in colorectal patients from 136/333 (41%) to 37/138 (27%), P=0.004.
Sanders G, Br J Anaesth. 2004;93(6):775 UK
根据Hct变化程度,分为:轻度血液稀释:Hct≥30%中度血液稀释:Hct20~29%
血液稀释(hemodilution) 降低Hct、减少红细胞丢失
中度血液稀释ASA推荐 Weiskopf , Transfusion 1995
血液稀释扩展到Hct20%或更低的程度能显著提高对手术失血的耐受性可应对相当大的手术失血量(4500ml)减少对异体输血的需要有经验的医师在"必需时"应用
中度血液稀释ASA推荐 Weiskopf , Transfusion 1995
方法为:1.血液稀释在手术失血前完成;2.在达到目标Hct时开始回输采出的血液,而且回输的速度与手术失血等同以维持目标Hct;3.在自体血输完后再开始输异体血;4.维持正常的血容量.
ANH的适应证
预计手术出血量500~2000ml的患者合并有红细胞增多症的手术患者因宗教信仰不接受异体血液输入者血型罕见,术中需要输血者等血源紧张时,需要手术者
ANH的禁忌证
xx前评估为ASA Ⅲ 级及以上者严重贫血或凝血功能障碍的患者接受大面积植皮或体表整形手术的患者因急性血液稀释可使手术创面的渗出量明显增加心功能不全或心脏内、外动静脉分流者有凝血病的病人术中没有大出血可能的病人血管条件差,采血困难者
输血的时机
尽可能在手术出血基本控制后输血大出血的当时快速补充血容量在全麻下允许短暂的Hct降低但要避免低血容量-维持组织灌注大出血的当时输血增加了失血量加重了凝血障碍不可机械刻板,应酌情灵活处理
术中自体血回收 CS
可回收手术野失血量的 50-70%生理盐水洗涤的压积红细胞( Hct 40-65% )洗除了90%以上的血浆成分、血小板、细胞碎屑、游离Hb和活性物质(xx的凝血物质、血小板、补体,以及FDPs等)
Cell Washing
洗涤红细胞的优点