圍術(shù)期自體輸血-課件

1、圍術(shù)期自體輸血 PPT課件圍術(shù)期自體輸血 PPT課件輸血存在的兩大問題血源性傳染病和輸血反應(yīng) 我國乙肝病毒（HBV）感染人數(shù)達1.1億，占總?cè)丝?%；90%丙肝由輸血傳播，輸血后丙肝發(fā)病率高達10%-20%，特殊人群中丙肝病毒（HCV）攜帶者達70%；我國HIV感染者已超過84萬，實際數(shù)？血源不足與濫用 我國年用血量超過1300噸，其中外科用血約占70%，臨床不必要的輸血占50%。輸血存在的兩大問題血源性傳染病和輸血反應(yīng)輸血原則安全、有效、節(jié)約輸血原則安全、有效、節(jié)約圍術(shù)期自體輸血-課件圍術(shù)期自體輸血-課件無血外科的概念1. 不輸血2. 自體輸血3. 成分輸血（異體）術(shù)前準備、手術(shù)技術(shù)麻醉、輸

2、血科管理醫(yī)院多處室協(xié)調(diào)目的：減少異體輸血無血外科的概念1. 不輸血2. 自體輸血3. 成分輸血術(shù)前準掌握輸血指征Transfusion Trigger:必須開始輸血的時機：Hb/Hct 和 綜合判斷10/30 rules: Hb10g/dl；Hct30 % 一般情況下，達到了這個標準就不必繼續(xù)輸血出手術(shù)室、出院時Overtransfusion: 在任何時候當輸血使得 Hct36% 時，就認為是過度輸血掌握輸血指征Transfusion Trigger:失血后不輸血的手術(shù)死亡率 術(shù)前Hb水平 死亡率（%）Carson 1988 失血后不輸血的手術(shù)死亡率 術(shù)前Hb水平 Hb Transfusion

3、 Trigger US 6g/dl：50歲，無心臟病和術(shù)后并發(fā)癥 8g/dl：穩(wěn)定性的心臟病，失血300ml10g/dl：老年人，術(shù)后有并發(fā)癥，心肺代償差Robertie：Int Anesthesiol Clin 28：197-204，199011g/dl（Hct33）：重危病人，強調(diào)維持適當?shù)难萘勘容斞匾狢zer and Shoemaker：Optimal hematocrit value in critically ill postoperative patients. Surg Gynecol Obstet 147: 363-368,1978Hb Transfusion Trigg

4、er US 6g衛(wèi)生部輸 血 指 南（2000年） Hb 100g/L 不必輸血 Hb 100g/出手術(shù)室的Hb/Hct標準Hb 8-9g/dl；Hct 25-27%ASA Status , 年青Hb 9-10g/dl；Hct 28-30%ASA Status Hb 11-12g/dl；Hct 33-35%ASA Status ，老年人 Hb 12g/dl； Hct 36% Overtransfusion 過度輸血出手術(shù)室的Hb/Hct標準Hb 8-9g/dl；Hct 25 推薦類別Class I Class IIa Class IIb Class III 證據(jù)水平Benefit Risk治療

5、應(yīng)當執(zhí)行Benefit Risk治療有理由執(zhí)行需要補充特定的研究Benefit Risk治療沒有理由不執(zhí)行需要補充廣泛的研究Risk Benefit治療不應(yīng)當執(zhí)行因為無益或有害Level A 多個 (3-5)人群的風險評估；一致的認識方向和明顯的療效。Recommendation that procedure or treatment is useful/effective Sufficient evidence from multiple randomized trials or meta-analyses Recommendation in favor of treatment or pr

6、ocedure being useful/effective Some conflicting evidence from multiple randomized trials or meta-analyses Recommendations usefulness/efficacy less well established Greater conflicting evidence from multiple randomized trials or meta-analyses Recommendation that procedure or treatment not useful/effe

7、ctive and may be harmful Sufficient evidence from multiple randomized trials or meta-analyses Level B 有限 (2-3)人群的風險評估Recommendation that procedure or treatment is useful/effectiveLimited evidence from single randomized trial or non-randomized studies Recommendation in favor of treatment or procedure

8、 being useful/effectiveSome conflicting evidence from single randomized trial or non-randomized studies Recommendations usefulness/efficacy less well established Greater conflicting evidence from single randomized trial or non-randomized studies Recommendation that procedure or treatment not useful/

9、effective and may be harmfulLimited evidence from single randomized trial or non-randomized studies Level C 極有限 (1-2)人群的風險評估Recommendation that procedure or treatment is useful/effectiveOnly expert opinion, case studies, or standard-of-care Recommendation in favor of treatment or procedure being use

10、ful/effectiveOnly diverging expert opinion, case studies, or standard-of-care Recommendations usefulness/efficacy less well established Only diverging expert opinion, case studies, or standard-of-care Recommendation that procedure or treatment not useful/effective and may be harmful Only expert opin

11、ion, case studies, or standard-of-care Classification Scheme Used to Summarize of Clinical Recommendations 推薦類別Class I ClassTransfusion TriggersClass IIaWith Hb 6 g/dL, RBC transfusion is reasonable, as this can be lifesaving. Transfusion is reasonable in most postoperative patients whose Hb=10 g/dL

12、, but more evidence to support this recommendation is required. (Level of evidence C)Class IIITransfusion is unlikely to improve oxygen transport when Hb10 g/dL and is not recommended. (Level of evidence C)Transfusion TriggersClass IIa綜合判斷輸血指征綜合分析，因人而異貧血持續(xù)的時間，血管內(nèi)的容積手術(shù)的范圍，大出血的可能性存在的合并癥：如肺功能障礙，心輸出量下降，

13、心肌缺血，腦血管或外周循環(huán)疾病。綜合判斷：術(shù)中通過對術(shù)野的觀察結(jié)合血標本的結(jié)果，對心肺功能的監(jiān)測綜合判斷出每一病人所能接受的最低Hb值。Consensus Conference: Red Blood Cell Transfusion. JAMA, 1998, 260: 2700-2703綜合判斷輸血指征綜合分析，因人而異取庫血前是否測 Hb/Hct ？原則上應(yīng)當測得 Hb/Hct 后再決定是否輸血（取血）大多數(shù)（ 90%），常規(guī)都要執(zhí)行但不絕對，結(jié)合臨床（90%)在輸血中或隨后評估效果及進一步的需要量減少誤判，節(jié)約血源和病人負擔某些例外是可能的 (90%)圍產(chǎn)期患者輸入紅細胞的合理性The a

14、ppropriateness of red blood cell transfusions in the peripartum patient1994 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,

15、2 units per womanmost commonly for postpartum bleeding (34% of cases). 16 adverse events from transfusion recorded.按照指南的標準，輸入的 248 個單位的 RBC (32%) 是不合適的！Obstet Gynecol. 2004;104(5 Pt 1):1000 Canada圍產(chǎn)期患者輸入紅細胞的合理性The appropriate提高自體輸血的比例管理指標：自體輸血的比例應(yīng)20%措施：提高自體血應(yīng)用量降低庫血的應(yīng)用量提高自體輸血的比例管理指標：圍術(shù)期自體輸血的種類儲存式 術(shù)前自

16、體獻血（ Preoperative Autologous Donation PAD）急性等容稀釋(Acute Normovolemic Hemodilution ANH) （Intraoperative Autologous Donation）急性高容稀釋(Acute Hypervolemic Hemodilution AHH)回收式（Blood Salvage BS）術(shù)中對自體血回收及回輸術(shù)后對自體血回收及回輸圍術(shù)期自體輸血的種類儲存式 應(yīng)當首選自體血避免血源傳播性疾病避免輸血的免疫反應(yīng)降低對庫血的需要量已備好或及時回收自體血，有利于挽救血液質(zhì)量高功能好應(yīng)當首選自體血避免血源傳播性疾病術(shù)前自

17、體獻血Preoperative Autologous Donation PAD擇期手術(shù)患者一般情況較好，Hb大于110g/L預(yù)計術(shù)中出血量超過循環(huán)血量15%稀有血型、配血困難；宗教信仰無心、肺、腎功能障礙無造血功能、凝血功能障礙無菌血癥術(shù)前自體獻血Preoperative Autologous術(shù)前需多次采血，給病人帶來不便可降低患者術(shù)前 Hb程序復(fù)雜，需要血庫儲存有成分的損耗（凝血因子等）血液保存時間有限，無法交互使用過期浪費的可能（50%），增加了費用采血和保存期有細菌污染的可能PAD 缺點 不常用術(shù)前需多次采血，給病人帶來不便PAD 缺點 不常用急性等容稀釋 (acute normovol

18、emic hemodilution ANH)ANH常用是有效和最經(jīng)濟的自體輸血方法可以直接采集全血，也可通過專用設(shè)備單采紅細胞采血的同時等量輸入非細胞溶液（膠體或晶體液）室溫保存，在手術(shù)室內(nèi)輸入Monk TG, Goodnough LT: Acute normovolemic hemodilution. Clin Orthop, 1998, 357:74-81急性等容稀釋 (acute normovolemic he血液稀釋技術(shù)血液稀釋技術(shù)血液黏度的降低外周血管阻力的下降心輸出量增加微循環(huán)改善組織氧攝取量的增加血紅蛋白-氧親和力降低血液稀釋代償血氧含量降低維持組織氧供病理生理學效應(yīng) 血液稀釋技

19、術(shù)血液黏度的降低外周血管阻力的下降心輸出量增加微循環(huán)改善組織氧Gross 公式計算邊采血邊輸液病人的采血量術(shù)前采血量（L） (采血前Hct -目標Hct) (采血前Hct+目標Hct)Gross JB: Estimating allowable blood loss: Corrected for dilution. Anesthesiology, 1983, 56: 577-580VL= EBV(HctO-HctF)/Hctave= 7體重（kg）2Gross 公式計算邊采血邊輸液病人的采血量= 7體重（kANH 的方法麻醉后手術(shù)前采集自身血同時輸入等量膠體液或3倍晶體液或不同比例的晶膠混合液

20、稀釋過程中保持血容量基本恒定術(shù)中血液有形成分丟失減少術(shù)終再將自體血反順序回輸ANH 的方法麻醉后手術(shù)前采集自身血Prospective RCT of ANH in major gastrointestinal surgeryAim : 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%)

21、 vs 55/82 (67%) (P=0.012).ANH 并不改變異體輸血率術(shù)前 Hb 水平、術(shù)中失血量和輸血規(guī)程是影響異體輸血的關(guān)鍵因素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

22、Prospective RCT of ANH in majo根據(jù)Hct變化程度，分為：輕度血液稀釋：Hct30%中度血液稀釋：Hct2029%血液稀釋(hemodilution) 降低Hct、減少紅細胞丟失血液稀釋(hemodilution) 降低Hct、減少紅細中度血液稀釋ASA推薦 Weiskopf , Transfusion 1995血液稀釋擴展到Hct20%或更低的程度能顯著提高對手術(shù)失血的耐受性可應(yīng)對相當大的手術(shù)失血量（4500ml）減少對異體輸血的需要有經(jīng)驗的醫(yī)師在“必需時”應(yīng)用中度血液稀釋ASA推薦 Weiskopf , Transf中度血液稀釋ASA推薦 Weiskopf ,

23、Transfusion 1995方法為：1血液稀釋在手術(shù)失血前完成；2.在達到目標Hct時開始回輸采出的血液，而且回輸?shù)乃俣扰c手術(shù)失血等同以維持目標Hct；3.在自體血輸完后再開始輸異體血；4.維持正常的血容量。 中度血液稀釋ASA推薦 Weiskopf , TransfANH的適應(yīng)證預(yù)計手術(shù)出血量5002000ml的患者合并有紅細胞增多癥的手術(shù)患者因宗教信仰不接受異體血液輸入者血型罕見，術(shù)中需要輸血者等血源緊張時，需要手術(shù)者ANH的適應(yīng)證預(yù)計手術(shù)出血量5002000ml的患者ANH的禁忌證麻醉前評估為ASA 級及以上者嚴重貧血或凝血功能障礙的患者接受大面積植皮或體表整形手術(shù)的患者因急性血液稀

24、釋可使手術(shù)創(chuàng)面的滲出量明顯增加心功能不全或心臟內(nèi)、外動靜脈分流者有凝血病的病人術(shù)中沒有大出血可能的病人血管條件差，采血困難者ANH的禁忌證麻醉前評估為ASA 級及以上者輸血的時機盡可能在手術(shù)出血基本控制后輸血大出血的當時快速補充血容量在全麻下允許短暫的Hct降低但要避免低血容量維持組織灌注大出血的當時輸血增加了失血量加重了凝血障礙不可機械刻板，應(yīng)酌情靈活處理輸血的時機盡可能在手術(shù)出血基本控制后輸血術(shù)中自體血回收 CS可回收手術(shù)野失血量的 50-70%生理鹽水洗滌的壓積紅細胞（ Hct 40-65% ）洗除了90%以上的血漿成分、血小板、細胞碎屑、游離Hb和活性物質(zhì)（激活的凝血物質(zhì)、血小板、補體

25、，以及FDPs等）術(shù)中自體血回收 CS可回收手術(shù)野失血量的 50-70%Cell WashingCell Washing洗滌紅細胞的優(yōu)點能迅速、及時地搶救病人紅細胞質(zhì)量高，2-3DPG，滲透脆性指數(shù)副作用小，(高鉀、酸中毒、游離Hb及活性物質(zhì)等)降低凈失血量Saved red cell is a lucky cell!洗滌紅細胞的優(yōu)點能迅速、及時地搶救病人紅細胞回收和其他降低圍術(shù)期異體輸血方法的效-價比Cost-effectiveness of CS and alternative methods of minimising perioperative allogeneic blood tra

26、nsfusionElectronic databases 1996-2004 for systematic reviews and 1994-2004 for economic evidence. Overall 668 studies Existing systematic reviews were updated with data from selected RCTs that involved adults scheduled for elective non-urgent surgeryCONCLUSIONS:The available evidence indicates that

27、 cell salvage may be a cost-effective method to reduce exposure to allogeneic blood transfusion. However, ANH may be more cost-effective than cell salvage.Davies L, Health Technol Assess. 2006 Nov;10(44):iii-iv, ix-x, 1-210, UK紅細胞回收和其他降低圍術(shù)期異體輸血方法的效-價比Cost-心血管外科的 CS心血管外科失血特點肝素化，創(chuàng)傷面積大，體外循環(huán) “機械損傷、血液與空氣

28、的接觸、以及血液與合成材料的接觸，可導致溶血、血小板和白細胞功能喪失、補體激活、凝血功能紊亂以及炎癥反應(yīng)等”心臟手術(shù)的術(shù)野污染最小，紅細胞回收率高，是最適合開展血液回收的手術(shù)類型。自體血回收的作用節(jié)約用血避免紅細胞碎片及游離血紅蛋白造成的損害減少魚精蛋白用量心血管外科的 CS心血管外科失血特點RED CELL AND PLATELET SAVINGClass IRoutine use of red cell saving is helpful for blood conservation in cardiac operations using CPB, except in patients with infection or malignancy. (Level of evidence A)Class IIIRoutine use of intraoperati