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临床时讯 > 临床研究


全文备索心脏手术前输血受质疑


  两项最新研究均显示,减少术前输血对于心脏手术患者而言是安全有益的策略。

  比利时Erasme大学医院的Vincent等开展TRACS试验,在巴西某医院入组502例心肺旁路术患者,随机分为两组,分别通过围手术期输红细胞将血细胞比容控制在≥24%(低输血率组,血红蛋白约8g/dl)和≥30%(高输血率组,血红蛋白约10g/dl)。结果显示,低输血率组和高输血率组的输血率分别为47%和78%(P>0.001)。两组30d总死亡/并发症(包括心源性休克、急性呼吸窘迫综合征和需要透析或血液滤过的急性肾损伤)发生率相似(10%∶11%,P=0.85)。不论采用哪种输血策略,每多输1单位的红细胞,30d总死亡或严重并发症发生风险即增加20%(P=0.002)。

  美国杜克大学医疗中心的Guerrero等从全美798家医院入组102470例接受冠状动脉旁路移植术(CABG)联合心肺旁路术的患者,开展观察性研究。结果显示,高输血率组在总死亡率方面对低输血率组不具有优势。虽然医院的地理位置、性质和规模均影响院内输血率,但各医院间在红细胞使用率上的差异,仅11.1%可用这3项因素解释,病例差异也仅能解释20.1%。研究者认为,临床医生对输血利弊的判断才是主要影响因素。

  美国斯坦福大学的Shander等在相关述评中指出,上述研究结果强烈提示,大量输血是不合理的,可增加并发症风险和费用,且增加了血液供应的压力。鉴于旨在减少不合理输血的指南收效甚微,需要采取更强力的措施,例如对患者血液管理进行认证,并将其纳入医疗机构质量考核指标。

JAMA. 2010 Oct 13;304(14):1559-67.

Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial.

Hajjar LA, Vincent JL, Galas FR, Nakamura RE, Silva CM, Santos MH, Fukushima J, Kalil Filho R, Sierra DB, Lopes NH, Mauad T, Roquim AC, Sundin MR, Leao WC, Almeida JP, Pomerantzeff PM, Dallan LO, Jatene FB, Stolf NA, Auler JO Jr.

Surgical Intensive Care Unit and Department of Anesthesiology, Heart Institute (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil.


Abstract

CONTEXT: Perioperative red blood cell transfusion is commonly used to address anemia, an independent risk factor for morbidity and mortality after cardiac operations; however, evidence regarding optimal blood transfusion practice in patients undergoing cardiac surgery is lacking.

OBJECTIVE: To define whether a restrictive perioperative red blood cell transfusion strategy is as safe as a liberal strategy in patients undergoing elective cardiac surgery.

DESIGN, SETTING, AND PATIENTS: The Transfusion Requirements After Cardiac Surgery (TRACS) study, a prospective, randomized, controlled clinical noninferiority trial conducted between February 2009 and February 2010 in an intensive care unit at a university hospital cardiac surgery referral center in Brazil. Consecutive adult patients (n = 502) who underwent cardiac surgery with cardiopulmonary bypass were eligible; analysis was by intention-to-treat.

INTERVENTION: Patients were randomly assigned to a liberal strategy of blood transfusion (to maintain a hematocrit ≥30%) or to a restrictive strategy (hematocrit ≥24%).

MAIN OUTCOME MEASURE: Composite end point of 30-day all-cause mortality and severe morbidity (cardiogenic shock, acute respiratory distress syndrome, or acute renal injury requiring dialysis or hemofiltration) occurring during the hospital stay. The noninferiority margin was predefined at -8% (ie, 8% minimal clinically important increase in occurrence of the composite end point).

RESULTS: Hemoglobin concentrations were maintained at a mean of 10.5 g/dL (95% confidence interval [CI], 10.4-10.6) in the liberal-strategy group and 9.1 g/dL (95% CI, 9.0-9.2) in the restrictive-strategy group (P < .001). A total of 198 of 253 patients (78%) in the liberal-strategy group and 118 of 249 (47%) in the restrictive-strategy group received a blood transfusion (P < .001). Occurrence of the primary end point was similar between groups (10% liberal vs 11% restrictive; between-group difference, 1% [95% CI, -6% to 4%]; P = .85). Independent of transfusion strategy, the number of transfused red blood cell units was an independent risk factor for clinical complications or death at 30 days (hazard ratio for each additional unit transfused, 1.2 [95% CI, 1.1-1.4]; P = .002).

CONCLUSION: Among patients undergoing cardiac surgery, the use of a restrictive perioperative transfusion strategy compared with a more liberal strategy resulted in noninferior rates of the combined outcome of 30-day all-cause mortality and severe morbidity.

TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01021631.

PMID: 20940381

JAMA. 2010 Oct 13;304(14):1568-75.

Variation in use of blood transfusion in coronary artery bypass graft surgery.

Bennett-Guerrero E, Zhao Y, O'Brien SM, Ferguson TB Jr, Peterson ED, Gammie JS, Song HK.

Division of Perioperative Clinical Research, Duke Clinical Research Institute, Duke University Medical Center, PO Box 3094, Durham, NC 27710, USA.


Abstract

CONTEXT: Perioperative blood transfusions are costly and have safety concerns. As a result, there have been multiple initiatives to reduce transfusion use. However, the degree to which perioperative transfusion rates vary among hospitals is unknown.

OBJECTIVE: To assess hospital-level variation in use of allogeneic red blood cell (RBC), fresh-frozen plasma, and platelet transfusions in patients undergoing coronary artery bypass graft (CABG) surgery.

DESIGN, SETTING, AND PATIENTS: An observational cohort of 102,470 patients undergoing primary isolated CABG surgery with cardiopulmonary bypass during calendar year 2008 at 798 sites in the United States, contributing data to the Society of Thoracic Surgeons Adult Cardiac Surgery Database.

MAIN OUTCOME MEASURES: Perioperative (intraoperative and postoperative) transfusion of RBCs, fresh-frozen plasma, and platelets.

RESULTS: At hospitals performing at least 100 on-pump CABG operations (82,446 cases at 408 sites), the rates of blood transfusion ranged from 7.8% to 92.8% for RBCs, 0% to 97.5% for fresh-frozen plasma, and 0.4% to 90.4% for platelets. Multivariable analysis including data from all 798 sites (102,470 cases) revealed that after adjustment for patient-level risk factors, hospital transfusion rates varied by geographic location (P = .007), academic status (P = .03), and hospital volume (P < .001). However, these 3 hospital characteristics combined only explained 11.1% of the variation in hospital risk-adjusted RBC usage. Case mix explained 20.1% of the variation between hospitals in RBC usage.

CONCLUSION: Wide variability occurred in the rates of transfusion of RBCs and other blood products, independent of case mix, among patients undergoing CABG surgery with cardiopulmonary bypass in US hospitals in an adult cardiac surgical database.

PMID: 20940382

Comment in:

JAMA. 2010 Oct 13;304(14):1610-1.

Blood transfusion as a quality indicator in cardiac surgery.

Shander AS, Goodnough LT.

PMID: 2094039

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