【亮.分享】血小板输注：美国血库学会临床实践指南

猪猪飞奔 2018-09-06

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血小板输注：美国血库联会(AABB)临床实践指南

Platelet Transfusion: A Clinical Practice Guideline From the AABB

Richard M. Kaufman, MD; Benjamin Djulbegovic, MD, PhD; Terry Gernsheimer, MD; Steven Kleinman, MD; Alan T. Tinmouth, MD; Kelley E. Capocelli, MD; Mark D. Cipolle, MD, PhD; Claudia S. Cohn, MD, PhD; Mark K. Fung, MD, PhD; Brenda J. Grossman, MD, MPH; Paul D. Mintz, MD; Barbara A. O’Malley, MD; Deborah A. Sesok-Pizzini, MD; Aryeh Shander, MD; Gary E. Stack, MD, PhD; Kathryn E. Webert, MD, MSc; Robert Weinstein, MD; Babu G. Welch, MD; Glenn J. Whitman, MD; Edward C. Wong, MD; and Aaron A.R. Tobian, MD, PhD

Background: Platelet transfusions are administered to prevent or treat bleeding in patients with quantitative or qualitative platelet disorders. The AABB (formerly, the American Association of Blood Banks) developed this guideline on appropriate use of platelet transfusion in adult patients.

背景：对于血小板数量或质量异常的患者，常常通过输注血小板预防或治疗出血。AABB制订了这一指南以指导在成年患者正确输注血小板。

Methods: These guidelines are based on a systematic review of randomized, clinical trials and observational studies that reported clinical outcomes on patients receiving prophylactic or therapeutic platelet transfusions. A literature search from 1900 to September 2014 with no language restrictions was done. Examined outcomes included all-cause mortality, bleeding-related mortality, bleeding, and number of platelet units transfused. An expert panel reviewed the data and developed recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

方法：通过系统性回顾有关预防性或治疗性输注血小板的随机临床试验及观察性研究，制定了本指南。文献检索自1900年到2014年9月，且无语言限制。检验的预后指标包括全因病死率、出血相关病死率、出血事件及血小板输注量。由一个专家小组回顾数据并按照GRADE分级制定指南。

Recommendation 1: The AABB recommends that platelets should be transfused prophylactically to reduce the risk for spontaneous bleeding in hospitalized adult patients with therapy induced hypoproliferative thrombocytopenia. The AABB recommends transfusing hospitalized adult patients with a platelet count of 10 x 10^9 cells/L or less to reduce the risk for spontaneous bleeding. The AABB recommends transfusing up to a single apheresis unit or equivalent. Greater doses are not more effective, and lower doses equal to one half of a standard apheresis unit are equally effective (Grade: strong recommendation; moderate-quality evidence).

推荐意见1：对治疗引起的生成障碍性血小板减少的成年住院患者，AABB推荐预防性输注血小板以降低自发出血风险。建议血小板输注阈值为< 10 x 10^9/L。建议输注量为1个单位或等同剂量的单采血小板。输注更大量的血小板并不能带来更多获益，输注半个单位的血小板也同样有效。（Grade：强烈推荐，中等质量证据）

Recommendation 2: The AABB suggests prophylactic platelet transfusion for patients having elective central venous catheter placement with a platelet count less than 20 x 10^9 cells/L (Grade: weak recommendation; low-quality evidence).

推荐意见2：AABB建议对血小板计数< 20 x 10^9/L且择期行中心静脉置管的患者预防性输注血小板。（Grade：弱推荐，低质量证据）

Recommendation 3: The AABB suggests prophylactic platelet transfusion for patients having elective diagnostic lumbar puncture with a platelet count less than 50 x 10^9 cells/L (Grade: weak recommendation; very low-quality evidence).

推荐意见3：AABB建议对血小板计数< 50 x 10^9/L且择期行诊断性腰椎穿刺的患者预防性输注血小板。（Grade：弱推荐，极低质量证据）

Recommendation 4: The AABB suggests prophylactic platelet transfusion for patients having major elective nonneuraxial surgery with a platelet count less than 50 x 10^9 cells/L (Grade: weak recommendation; very low-quality evidence).

推荐意见4：AABB建议对血小板计数< 50 x 10^9/L且择期行非神经轴索手术的患者预防性输注血小板。（Grade：弱推荐，极低质量证据）

Recommendation 5: The AABB recommends against routine prophylactic platelet transfusion for patients who are nonthrombocytopenic and have cardiac surgery with cardiopulmonary bypass (CPB). The AABB suggests platelet transfusion for patients having CPB who exhibit perioperative bleeding with thrombocytopenia and/or evidence of platelet dysfunction (Grade: weak recommendation; very low-quality evidence).

推荐意见5：对接受体外循环(CPB)心脏手术的患者，如无血小板减少症，AABB反对常规预防性输注血小板。对存在血小板减少症和（或）有血小板功能异常证据，发生围手术期出血的CPB患者，AABB建议输注血小板。（Grade：弱推荐，极低质量证据）

Recommendation 6: The AABB cannot recommend for or against platelet transfusion for patients receiving antiplatelet therapy who have intracranial hemorrhage (traumatic or spontaneous) (Grade: uncertain recommendation; very low-quality evidence).

推荐意见6：对接受抗血小板药物治疗的（创伤性或自发性）颅内出血患者是否输注血小板，AABB不提供推荐意见。（Grade：不确定，极低质量证据）

Ann Intern Med. doi:10.7326/M14-1589

www.annals.org

From MEDSCAPE Website

Annals of Internal Medicine于11月11日在线发表有关成年患者输注血小板的新指南。指南强调，应当谨慎输注血小板以降低患者风险并节约血液资源。

Brigham & Women医院成人输血科主任和哈佛医学院病理学助理教授Richard Kaufman及其同事对报告临床预后的相关RCT及观察性研究进行了系统回顾，并根据分级系统制定了推荐意见。该研究小组由21名专家组成，包括病理科医生、血液科医生、神经外科医生、心脏外科医生、重症医学医生、麻醉医生以及一名分级方法学专家。

他们制订了6条推荐意见：1条基于中等质量证据的强烈推荐意见，4条基于低质量证据的弱推荐意见，以及1条基于低质量证据的不确定意见。

在强烈推荐意见中，对治疗引起的生成障碍性血小板减少和晨起血小板计数< 10 x 10^9/L的成年患者，AABB强调通过预防性输注血小板以降低自发出血风险。他们写到，输注相当于半量标准单位的血小板也同样有效。

基于3项RCT共1047名血液系统恶性肿瘤的住院患者的分析发现，预防性输注血小板可将2级或2级以上的自发性出血风险降低约一半(OR = 0.53, 95% CI: 0.32-0.87)。

此外，共包括658患者的4项RCT数据显示，更高的血小板输注阈值并不降低2级或2级以上出血的发生率(OR = 0.74, 95% CI: 0.41-1.35)或出血相关病死率(OR = 0.37, 95%CI: 0.02-9.22)。以10 x 10^9/L作为输注血小板阈值，可减少血小板用量，并减少输血反应。

观察性研究结果

第2条推荐意见是对血小板计数< 20 x 10^9/L的择期中心静脉置管患者预防性输注血小板。尽管这一推荐意见基于低质量证据，因而推荐力度较弱，但专家组认为有足够的观察性研究结果支持这一意见。

Kaufman 医生告诉Medscape医学新闻频道，“我们的确发现，对于接受中心静脉置管进行肿瘤相关治疗的特殊患者，现有的观察性研究足以支持在实施特殊操作时采用较低的血小板输注阈值即20 x 10^9/L。这一阈值低于其他人的推荐意见。我们相信这样可以降低输血风险，同时也能节约血小板资源，而且不会增加出血不良事件的风险。”

他补充道：“我们发现有几项RCT关注治疗相关的生成障碍性血小板减少，但我们也惊讶地发现其他领域的数据极为有限，我们认为这是将来研究的契机。”