患者血液管理程序改善血液使用和骨科手术的临床结果
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Patient Blood Management Program Improves Blood Use and Clinical Outcomes in Orthopedic Surgery
背景与目的
虽然随机试验显示，患者在输血较少的情况下表现良好，但骨科手术患者比其他患者需要更高的血红蛋白输血阈值(8 g/dl vs. 7 g/dl)的印象依然存在。作者在骨科患者中验证了这一假设，实施患者血液管理程序即建议阈值为血红蛋白值低于7 g/dl，会导致用血减少，但临床结果没有变化。
方 法
虽然随机试验显示，患者在输血较少的情况下表现良好，但骨科手术患者比其他患者需要更高的血红蛋白输血阈值(8 g/dl vs. 7 g/dl)的印象依然存在。作者在骨科患者中验证了这一假设，实施患者血液管理程序即建议阈值为血红蛋白值低于7 g/dl，会导致用血减少，但临床结果没有变化。
结 果
患者血液管理实施后，平均血红蛋白阈值由7.8 g/dl下降到6.8 g/dl (P < 0.0001)。红细胞用量下降32.5%(从338单位/ 1000例下降到228单位/ 1000例;P = 0.0007)。临床疗效改善，发病率降低(从1.3%降至0.54%);P = 0.01)、复合发病率或死亡率(1.5% ~ 0.75%);P = 0.035)， 30天再入院率(9.0% ~ 5.8%;P = 0.0002)。主要在65岁及以上的患者中结果得到改善。风险调整后，患者血液管理与降低综合发病率或死亡率独立相关(优势比0.44;95% CI, 0.22~0.86;P = 0.016)。
结 论
在此项回顾性研究中，骨科手术患者的血液管理与减少用血以及类似或改善临床结果有关。血红蛋白阈值7g/dl似乎对许多骨科患者来说是安全的。
原始文献摘要
Background: Although randomized trials show that patients do well when given less blood, there remains a persistent impression that orthopedic surgery patients require a higher hemoglobin transfusion threshold than other patient populations (8 g/ dl vs. 7 g/dl). The authors tested the hypothesis in orthopedic patients that implementation of a patient blood management program encouraging a hemoglobin threshold less than 7 g/dl results in decreased blood use with no change in clinical outcomes.
Methods: After launching a multifaceted patient blood management program, the authors retrospectively evaluated all adult orthopedic patients, comparing transfusion practices and clinical outcomes in the pre- and post-blood management cohorts. Risk adjustment accounted for age, sex, surgical procedure, and case mix index.
Results: After patient blood management implementation, the mean hemoglobin threshold decreased from 7.8 1.0 g/dl to 6.8 1.0 g/dl (P < 0.0001). Erythrocyte use decreased by 32.5% (from 338 to 228 erythrocyte units per 1,000 patients; P = 0.0007). Clinical outcomes improved, with decreased morbidity (from 1.3% to 0.54%; P = 0.01), composite morbidity or mortality (from 1.5% to 0.75%; P = 0.035), and 30-day readmissions (from 9.0% to 5.8%; P = 0.0002). Improved outcomes were primarily recognized in patients 65 yr of age and older. After risk adjustment, patient blood management was independently associated with decreased composite morbidity or mortality (odds ratio, 0.44; 95% CI, 0.22 to 0.86; P = 0.016).
Conclusions: In a retrospective study, patient blood management was associated with reduced blood use with similar or improved clinical outcomes in orthopedic surgery. A hemoglobin threshold of 7 g/dl appears to be safe for many orthopedic patients
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