输血管理的经验交流会幻灯围术期自体输血.pptVIP

围术期自体输血 首都医科大学 北京友谊医院 麻醉科 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 Methods Hemostasis (Surgical / Medicine) Transfusion Trigger Indications for Blood Transfusion Autotransfusion Preoperative Autologous Donation (PAD) Acute Normovolemic Hemodilution (ANH) Intraoperative Autologous Donation Red 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 surgery 1980 to 1985 early practice group; n = 699 1995 to 2000 late practice group; n = 610 Compared 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 无血外科的概念 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（%） 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300ml 10g/dl：老年人，术后有并发症，心肺代偿差 Robertie：Int Anesthesiol Clin 28：197-204，1990 11g/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） 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 Ⅲ Hb 11-12g/dl；Hct 33-35% ASA Status Ⅳ Ⅴ，老年人 Hb ＞ 12g/dl； Hct ＞36% Overtransfusion 过度输血 Transfusion Triggers Class IIa With Hb 6 g/dL, RBC transfusion is reasonable, as this can be lifesaving. Transfusion is reasonable in most postoperative patients whose Hb7 g/dL, but no high-level evidence supports this recommendation.