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,1,主要内容,询证输血医学新观念 现代输血疗法的临床应用,2,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,3,Crit Care Med 2009 Vol. 37, No. 12. 3124,Crit Care Med 2004; 32Suppl.:S542S547,意大利国家指南 Blood Transfus 2009; 7: 49-64,Annals of Internal Medicine 2012 ； 157（1）：50,输血作为支持疗法不再是现代红细胞输注指征,4,败血症患者要求较高Hb水平的适应证不包括支持目的,Conditions in septic patients that may require a higher hemoglobin Acute instability Cardiovascular disease Coronary artery disease Low cardiac output Pulmonary disease Severe arterial hypoxemia Organ or tissue ischemia Severe mixed venous desaturation（混合静脉血氧饱和度，过低表明组织氧合障碍） Elevated lactate level Use of blood products in sepsis: An evidence-based review. Crit Care Med 2004; 32(Suppl):S542S547.,5,FFP适应证不包括抗感染输注FFP不能作为支持疗法,Fresh-Frozen Plasma Transfusion Question: When should FFP be transfused in patients with severe sepsis? Recommendation: Routine use of FFP to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures is not recommended. FFP is indicated for coagulopathy due to documented deficiency of coagulation factors (increased PT APTT) in the presence of active bleeding or before surgical or invasive procedures. Use of blood products in sepsis: An evidence-based review. Crit Care Med 2004; 32(Suppl):S542S547.,6,重症患者输注红细胞导致的不良转归,From 571 articles screened, 45 met inclusion criteria In 42 of the 45 studies the risks of RBC transfusion outweighed the benefits; Seventeen of 18 studies, demonstrated that RBC transfusions were an independent predictor of death; Twenty-two studies examined the association between RBC transfusion and nosocomial infection; in all these studies blood transfusion was an independent risk factor for infection. RBC transfusions similarly increased the risk of developing multi-organ dysfunction syndrome (three studies) and acute respiratory distress syndrome (six studies). Marik PE, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literatureJ. Crit Care Med. 2008;36(9):2667-2674,7,相对危险度,腹腔间隙综合征,8,9,10,Prospective, multiple center, observational cohort study（观测队列研究） of 4,892 ICU pts in the US Propensity score（倾向指数） matched Designed to examine the relationship of anemia and RBC transfusion with clinical outcomes Almost 95% of patients admitted to the ICU have a Hb level below “normal” by day 3 In total, 11,391 RBC units were transfused. Overall, 44% of pts admitted to the ICU received one or more RBC units while in the ICU,Crit Care Med. 2004 Jan;32(1):39-52,11,The mean pre-transfusion Hb was 8.6 1.7 g/dL,RBC transfusion was independently associated with higher mortality (OR 1.65 CI 1.35-2.03). OR 2.62 if 3-4 units transfused p 0.0001,35% of Blood transfused in patients with Hgb 9,Crit Care Med. 2004 Jan;32(1):39-52,12,Analysis of 24,112 enrollees in 3 large international trials of patients with acute coronary syndromes Association between transfusion and outcome Cox proportional hazards modeling Main outcome = 30 day mortality,Rao SV et al. JAMA. 2004;292:1555-1562,13,Blood Transfusion and Clinical Outcome in Acute Coronary Syndrome,Rao SV et al. JAMA. 2004;292:1555-1562,Transfusion,No Transfusion,Adjusted hazard ratio 3.94 (3.26-4.75),14,研究对象,研究结论,15,老年退伍军人局,16,17,15,592 Cardiovascular operations Infection endpoints bacteremia, SSI 55% of pts received PRBCs, 21% plts, 13% FFP, 3% cryoprecipitate Increased RBC tx associated with increased infection (p 0.0001), confirmed by logistic regression analysis.,J Am Coll Surg 2006;202:131-138,18,Effect of Blood Transfusion on Long-Term SurvivalAfter Cardiac Operation,1915 CABG pts After correction for comorbidities and other factors, tx was still associated with a 70% increase in mortality (RR 1.7; 95% CI 1.4 to 2.0; p 0.001).,Engoren MC et al. (MCO, Toledo) Ann Thorac Surg 2002;74:11806,19,患者输注红细胞导致的不良转归机制,Storage lesion 库存红细胞2.3-DPG含量下降 Metabolic acidosis Altered oxygen carrying capacity 库存红细胞变形能力下降 库存红细胞携带NO能力减弱 Increased red cell death with increased age of blood (30% dead) No improvement in oxygen utilization at the tissue level 同种输血的免疫负向调节作用,20,21,22,研究结果,The median duration of storage was 11 days for newer blood and 20 days for older blood. Patients who were given older units had higher rates of in-hospital mortality (2.8% vs. 1.7%, P = 0.004), intubation beyond 72 hours (9.7% vs. 5.6%, P0.001), renal failure (2.7% vs. 1.6%, P = 0.003), and sepsis or septicemia (4.0% vs. 2.8%, P = 0.01). A composite of complications was more common in patients given older blood (25.9% vs. 22.4%, P = 0.001). Similarly, older blood was associated with an increase in the risk-adjusted rate of the composite outcome (P = 0.03). At 1 year, mortality was significantly less in patients given newer blood (7.4% vs. 11.0%, P0.001).,23,Immune Effects of Blood,Immunologic effects of allogenic blood Tx Decreased T-cell proliferation Decreased CD3,