【医学课件】-输血治疗传统观念的变革与更新

,单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,【医学ppt课件】 输血治疗传统观念的变革与更新,【医学ppt课件】 输血治疗传统观念的变革与更新,【医学课件】-输血治疗传统观念的变革与更新,【医学课件】-输血治疗传统观念的变革与更新,.,Animal to human - Jean Denis , 1667,.,Human to human,-,1818, James Blundell,-,1900 The elucidation of the ABO blood group system by Landsteiner,-,1914 Lewisohn,- used citrate,- 1940 Landsteiner and Wiener, in, describe Rh typing,4,. 4,成分输血的简史,输血医学发展的第二个里程碑是成分输血，早期的输血都是输注全血，1950年Walter发明了塑料血袋，使血液分离较为便利，血液成分疗法正式提出。随着塑料多联血袋的问世，二十世纪六十年代起输血医学进入了成分输血时代。美国成分输血发展为例，浓缩红细胞输血的比例19671978年间，由0.8%增加到88。临床输血的主流是红细胞，节省的大量血浆可用于制备因子，用来治疗血友病。粒细胞输注趋势；血小板的输注也具有明显上升的趋势。,5,成分输血的简史5,成分输血的意义,提高输血疗效,减少和预防输血不良反应和并发症,*,有利于血液各种成分的保存,节约血液资源,6,成分输血的意义提高输血疗效6,减少和预防输血不良反应和并发症,输注添加液红细胞，可减少或避免输注血浆导致的过敏反应，这种反应占42.6%；,输注去白细胞红细胞或血小板可避免或减少以后患者输血由于产生白细胞抗体而发生的非溶血性发热输血反应，这种反应占52.6%。避免HLA同种免疫，避免今后器官或骨髓移植的超急性排斥反应；可避免血小板输注无效等；,减少输血感染病毒的危险性；,为血液成分的病毒灭活创造条件。,7,减少和预防输血不良反应和并发症输注添加液红细胞，可减少或避免,现代成分输血的主要趋势,输注添加液红细胞为主流；,血小板输注的增加；,去白细胞血液成分广泛应用；,病毒灭活血液成分临床应用；,特殊成分的输注 外周血干细胞移植 DC抗肿瘤疫苗；,白细胞输注减少；,促进血细胞生长的药物的应用，减少了血液成分的使用量。rhEpo , G-CSF,8,现代成分输血的主要趋势输注添加液红细胞为主流；8,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出现不良转归,输血不能促进伤口愈合,“失多少血，补多少血”“缺多少血，补多少血”是过时、错误观念,9,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9,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,10,Crit Care Med 2009 Vol. 37, No,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,Cardiovascular disease,Coronary artery disease,Low cardiac output,Pulmonary disease,Severe arterial hypoxemia（低氧血症）,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.,11,败血症患者要求较高Hb水平的适应证不包括支持目的,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.,12,FFP适应证不包括抗感染输注FFP不能作为支持疗法 F,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 literature J. Crit Care Med. 2008;36(9):2667-2674,13,重症患者输注红细胞导致的不良转归From 571 artic,相对危险度,腹腔间隙综合征,14,相对危险度腹腔间隙综合征14,15,15,16,16,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):39-52,17,Prospective, multiple center,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):39-52,18,The mean pre-transfusion Hb wa,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;292:1555-1562,19,Analysis of 24,112 enrollees i,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),20,Blood Transfusion and Clinical,研究对象,研究结论,21,研究对象研究结论21,老年退伍军人局,22,老年退伍军人局22,23,23,15,592 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,（回归分析）,.,J Am Coll Surg 2006;202:131-138,24,15,592 Cardiovascular operatio,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;74:11806,25,Effect of Blood Transfusion on,26,26,Methods,We enrolled,838,critically ill patients who had hemglobin concentrations of less than,9.0 g /dl,and randomly assigned,418,patients to a,restrictive strategy of transfusion, in which red cells were transfused if the hemoglobin concentration dropped below 7.0 g /dl and hemoglobin concentrations were maintained at,7.0 to 9.0 g /dl,and,420,patients to a liberal strategy, in which transfusions were given when the hemoglobin concentration fell below 10.0 g /dl and hemoglobin concentrations were maintained at,10.0 to 12.0 g /dl.,Results,Overall,30-day mortality,was,similar,in the two groups (18.7 percent vs. 23.3 percent, P=0.11).,The mortality rate during hospitalization,was,significantly lower,in the restrictive-strategy group (22.2 percent vs. 28.1 percent, P=0.05).,27,Methods27,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,28,患者输注红细胞导致的不良转归机制Storage lesion,29,29,March 20, 2008,30,March 20, 200830,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%, P30时，除了及时补液和输注红细胞外，可根据患者具体情况加输全血、FFP或血小板。,57,失血量与输血指征关系患者丢失20（新生儿10%）的血容量以,临床输血技术规范,手术及创伤输血指南一、浓缩红细胞 用于需要提高血液携氧能力，血容量基本政常或低血容量已被纠正的患者。低血容量患者可配晶体液或胶体液应用。1 血红蛋白100g/L,可以不输。2 血红蛋白70g/L,应考虑输。3 血红蛋白在70-100g/L 之间，根据患者的贫血程度、心肺代偿功能、有无代谢率增高以及年龄等因素决定。,58,临床输血技术规范58,59,59,英国红细胞输注指南（2002年）,60,英国红细胞输注指南（2002年）60,临床情况,心肺功能受损或伴有心脑血管病变的患者，由于心肺功能状况可直接影响机体耐受和代偿因急性失血引起的组织供氧不足，因此应当适当放宽输血指征；,患者失血前有无贫血及贫血程度：,患者骨髓和肝脏功能状况等也是在急性出血后是否输血，选择血液制品种类及输血剂量的重要因素。,61,临床情况心肺功能受损或伴有心脑血管病变的患者，由于心肺功能状,血小板输注,血小板输注原则,预防性血小板输注,治疗性血小板输注,外科患者的血小板输注,血小板输注后的疗效评价,62,血小板输注血小板输注原则62,血小板输注原则,血小板输血疗法主要应用在防止患者出血或治疗活动性出血。在临床上决定是否需要输注血小板以及输注剂量主要取决于患者临床情况、血小板减少的原因、血小板计数、患者血小板的功能。,63,血小板输注原则 血小板输血疗法主要应用在,安医大附院机采血小板使用情况,64,安医大附院机采血小板使用情况64,美国与我院输注血小板比较,65,美国与我院输注血小板比较65,2006年安徽省和我院临床输注血液和血小板比例,全血和红细胞输注量 血小板输注量 比例,我院 18004 1173 15：1,全省 417000 117 13 35（33）：1,注：全省置备手工9901单位,Asfourb报道,美国红细胞:血小板=2.88:1,66,2006年安徽省和我院临床输注血液和血小板比例,This study was performed at the University of Texas MD Anderson Cancer Center, Houston, where we transfuse approximately 32,309 packed red blood cells (RBCs), 87,760 random-donor platelets 4878 single donor platelets 8958 units of fresh frozen plasma 549 granulocytes, and 1553 cryoprecipitate units annually.,Transfusion of RhD-Incompatible Blood Components in RhD-Negative Blood Marrow Transplant Recipients,M. Asfour, MD, Aida Narvios, MD, and Benjamin Lichtiger, MBA, MD, PhD.MedGenMed.,2004; 6(3): 22.,67,This study was performed at th,预防性血小板输注的有关问题,血小板输注剂量,一般预防性血小板输注剂量为每10Kg体重输注2单位血小板/d或1个治疗量的机采血小板。目前尚无证据表明此类患者需要输注更大剂量的血小板。,计算公式,预计达到的Plt（mm,3,）患者原有的Plt（mm,3,）,1.42,5000,注：国外每单位血小板是由400ml全血中制备，国内是从200ml全血中制备；国外血小板每单位是7010,9,；国内2410,9,。,68,预防性血小板输注的有关问题血小板输注剂量 一般预防性血小,预防性血小板输注的有关问题,血小板输注指征,Plt 51010,9,/L；,长期输注血小板者,难以达到疗效时，应当应用CCI来判断血小板的输注效果；,患者血小板功能异常,例如服用阿司匹林和尿毒症，临床医生应当根据临床具体情况决定是否需要输注血小板，不要机械的根据PLT；,ITP患者血小板输注问题,69,预防性血小板输注的有关问题血小板输注指征 Plt 5,儿童血小板输注指征,70,儿童血小板输注指征70,输注血小板治疗活动性出血,患者PLT5010,9,/L并伴有活动性出血时，应当进行血小板输注。,71,输注血小板治疗活动性出血 患者PLT5010,9,/L，以利于损伤愈合及防止出血。,72,外科血小板输注较大的外科手术患者术前PLT最好维持在501,机采血小板输注适应证,73,机采血小板输注适应证73,血小板输注的疗效评估,对长期反复输注血小板者应当进行血小板疗效评估，确定下次血小板输注时间和剂量。,74,血小板输注的疗效评估 对长期反复输注血小,血小板纠正指数corrected count increment （CCI）,（输注后血小板计数输注前血小板计数）体表面积(m,2,),血小板纠正指数（CCI）,输注的血小板总数(10,11,),血小板计数单位是10,9,/L，输注后血小板计数,为输注后1小时Plt。,CCI1.5对照，伴急性出血或侵入性手术前出现下列情况：, 单个凝血因子缺乏（不包括血友病A/B）；, DIC;, 肝衰竭。,78,FFP输注适应症1. TTP;78,Guidelines for,the use of fresh-frozen plasma,British Journal of Haematology 2004; 126:11,Single inherited clotting factor deficiencies for which no virus-safe fractionated product is available. ex. Factor V,Multi-factor deficiencies associated with severe bleeding (ex.DIC with bleeding),Fresh-frozen plasma is not indicated in DIC with no evidence of bleeding.,Hypofibrinogenemia: Cryoprecipitate may be indicated if the plasma fibrinogen is less than 1 g/l,TTP:,Single volume daily plasma exchange should ideally be begun at presentation (gradeA recommendation, levelIb evidence),79,Guidelines for the use of fres,Guidelines for FFP,Surgical bleeding,:,Should be guided by timely tests of coagulation,FFP should never be used as a simple volume relacement in adults or children (grade B recommendation, level IIb evidence).,Massive transfusion:,If bleeding continues after large volumes of crystalloid, red cells and platelets have been transfused, FFP and cryoprecipitate may be given so that the PT and APTT ratios are shortened to within 1.5, and a fibrinogen concentration of at least 1.0 g/l in plasma obtained.,British Journal of Haematology 2004; 126:11,80,Guidelines for FFP Surgical,Guidelines for FFP,DIC,Treating the underlying cause is the cornerstone of managing DIC.,If the patient is bleeding, a combination of FFP, platelets and cryoprecipitate is indicated.,If there is no bleeding, blood products are not indicated, whatever the results of the laboratory tests, and,there is no evidence for prophylaxis with platelets or plasma,81,Guidelines for FFPDIC 81,Guidelines for FFP,Liver disease,Platelet count and function, as well as vascular integrity（完整）, may be more important in these circumstances.,The response to FFP in liver disease is unpredictable. Complete normalization of the haemostatic defect does not always occur. If FFP is given, coagulation tests should be repeated.,There is no evidence to substantiate（支持）,the practice in many liver units of undertaking liver biopsy only if the PT is within 4 s of the control (grade C recommendation, level IV evidence).,82,Guidelines for FFP82,Improper use of FFP,Improvement and correction of decreasing the circulating plasma volume,Nutritional supplementation as the source of protein,Promotion of wound healing,Treatment of severe infectious disease,treatment of burn without DIC,83,Improper use of FFPImprovement,临床输血的若干问题,术前输血,大量输血,相容血液输注问题,RhD不同血液成分输注问题,84,临床输血的若干问题术前输血84,术前输血,传统的术前Hb标准 术前Hb应维持在100g/L ；,国外学者研究发现，只有Hb30g/L才影响手术患者的预后；,目前的观点 除非患者伴有,冠心病、充血性心力衰竭、肺部疾病、动脉硬化或服用影响心脏不能增加心输出量和耐受贫血的药物（如阻滞剂），或者年龄超过65岁以上,，术前Hb应当维持在100g/L左右; Hb,5 units（RBC）,4-5 year old child,3 units （RBC）,2-3 year old child,2 units （RBC）,0-1 year old child,1 unit （RBC）,87,大量输血定义24小时内输血达到患者的全身的总血容量87,大量输血的并发症,88,大量输血的并发症88,Effect of Hypothermia on coagulation factor activity,89,Effect of Hypothermia on coagu,大量输血原因分析,病种 比例,外科手术 0.6%,创伤 29,胃肠道出血 31,心血管外科 12,肿瘤 9,妇产科急症 4,90,大量输血原因分析90,大量出血的输液输血疗法,第一阶段 输液疗法,恢复血管容量,第二阶段 输血疗法,恢复组织供氧,第三阶段 血液成分的补充,纠正凝血障碍,91,大量出血的输液输血疗法 第一阶段 输液疗法 恢复血管容量9,大量输血时血液,成分的选择和使用原则,最好输注全血,*,输注血小板 A dilutional effect on the platelet concentration can be seen with massive transfusion. In an adult, each 10 to 12 units of transfused red cells can produce a 50 percent fall in the platelet count; thus, significant thrombocytopenia can be seen after 10 to 20 units of blood, with platelet counts below 50,000/L.,PT和APTT延长1.5倍时，输注FFP 剂量： 1015ml/kg,纤维蛋白原1000mg/L输注冷沉淀 剂量：6-unit pool for fibrinogen levels between 500-1000 mg/L; 12-unit pool for fibrinogen levels 500mg/L.,92,大量输血时血液成分的选择和使用原则最好输注全血*92,Warm fresh whole blood transfusion for severe hemorrhage: U.S. military and potential civilian applications.,Spinella PC,.,Crit Care Med. 2008 Jul;36(7 Suppl):S340-5,Between March 2003 and July 2007, over 6000 units of warm fresh whole blood have been transfused in Afghanistan and Iraq by U.S. medical providers to patients with life-threatening traumatic injuries with hemorrhage. Preliminary results in approximately 500 patients with massive transfusion indicate that the amount of,fresh warm whole blood,transfused is independently associated with,improved 48-hr and 30-day survival,and the amount of,stored red blood cells,is independently associated with,decreased 48-hr and 30-day survival,for patients with traumatic injuries that require massive transfusion. Risks of warm fresh whole blood transfusion include the transmission of infectious agents.,93,Warm fresh whole blood transfu,CONCLUSIONS,For patients with life-threatening hemorrhage at risk for massive transfusion, if complete component therapy is not available or not adequately correcting coagulopathy, the risk:benefit ratio of warm fresh whole blood transfusion favors its use. In addition, recent evidence suggests that there is potential for,warm fresh whole blood to be more efficacious than stored component therapy,that includes stored red blood cells in critically ill patients requiring massive transfusion.,94,CONCLUSIONS For patients wi,Harke研究表明输注全血的患者凝血