围术期血液管理是指包括围术期输血以及减少失血、优化血液制品、减少输血相关风险和各种血液保护措施的综合应用等。 围术期输血是指在围术期输入血液或其相关成分,包括自体血以及异体全血、红细胞、血小板、新鲜冰冻血浆和冷沉淀等。成分输血是依据患者病情的实际需要,输入相关的血液成分。血液管理的其他措施包括为避免或减少失血及输入异体血所使用的药物和技术。
1. 填写《临床输血申请单》,签署《输血治疗同意书》; 2. 血型鉴定和交叉配血试验; 3. 咨询相关专科医师或会诊。择期手术患者应暂停抗凝治疗(例如华法林、抗凝血酶制剂达比加群酯),对特定患者可使用短效药(例如肝素、低分子量肝素)进行桥接治疗; 除有经皮冠状动脉介入治疗史的患者外,如果临床上可行,建议在术前较充足的时间内停用非阿司匹林类的抗血小板药(例如噻吩并吡啶类,包括氯吡格雷、替格瑞洛或普拉格雷);根据外科手术的情况,考虑是否停用阿司匹林; 4. 当改变患者抗凝状态时,需充分衡量血栓形成的风险和出血增加的风险; 5. 既往有出血史的患者应行血小板功能检测,判断血小板功能减退是否因使用抗血小板药所致; 6. 了解患者贫血的原因(慢性出血、缺铁性贫血、肾功能不全、溶血性贫血或炎症性贫血等),并根据病因治疗贫血,首先考虑铁剂治疗; 7.血液病患者术前应进行病因治疗和/或全身支持治疗,包括少量输血或成分输血、补铁、加强营养等; 8. 如患者选择自体输血且条件许可时,可在术前采集自体血; 9. Rh阴性和其他稀有血型患者,术前应备好预估的需要血量。 A.除常规监测外,术中出血患者应在血细胞比容、血红蛋白水平和凝血功能的监测下指导成分输血; B.围术期应维持患者前负荷,但要避免全身血容量过高。严重出血时,应考虑动态评估液体反应性和无创心排血量的监测,不应将中心静脉压和肺动脉楔压作为判断血容量的唯一标准; C.出现急性出血时,建议反复测量血细胞比容、血红蛋白、血清乳酸水平及酸碱平衡情况,以了解组织灌注、组织氧合及出血的动态变化。 成人: 浓缩红细胞补充量=(Hct预计值-Hct实测值)×55×体重/0.60 小儿: 红细胞补充量=(Hb预计值-Hb实测值)×体重×5(Hb单位为mg/dl) 大多数患者维持血红蛋白70g/L~80g/L(Hct21%~24%),存在心肌缺血、冠心病的患者维持血红蛋白100g/L(Hct30%)以上。 输注红细胞时,也可参考围术期输血指征评分(POTTS)决定开始输注的患者血红蛋白浓度及输注后的目标血红蛋白浓度。 上述四项总计分再加60分为POTTS总分。最高分为100分,即如果总分≥100分则算为100分,评分值对应启动输注RBCs且需维持的最低血红蛋白浓度。
(1)血小板制品:包括手工分离血小板、机器单采血小板。 (2)输注指征:用于血小板数量减少或功能异常伴异常渗血的患者。
(3)注意事项
用于围术期凝血因子缺乏的患者。研究表明北美洲、欧洲的白种人维持正常凝血因子浓度的30%或不稳定凝血因子仅需维持5%~20%,就可以达到正常凝血状况。 (1)血浆制品:包括新鲜冰冻血浆(FFP)、冰冻血浆和新鲜血浆。 (2)使用FFP的指征:
(3)使用说明
(2)以下情况应考虑输注冷沉淀:
(3)使用说明 A. 围术期纤维蛋白原浓度应维持在100mg/dl~150mg/dl之上,应根据伤口渗血及出血情况决定冷沉淀的补充量。在冷沉淀输注结束后,应临床评估、重复检测纤维蛋白原,若需要可再补充。 一个单位冷沉淀约含150mg纤维蛋白原,使用20单位冷沉淀可恢复到必要的纤维蛋白原浓度; B. 冷沉淀用于Ⅷ因子水平低下或缺乏的补充,按每单位冷沉淀含Ⅷ因子80IU估算。轻度、中度和重度Ⅷ因子水平低下或缺乏时,补充剂量分别为10IU/kg~15IU/kg、20IU/kg~30IU/kg和40IU/kg~50IU/kg; 用于纤维蛋白原水平低下或缺乏补充,按每单位冷沉淀含纤维蛋白原150mg估算,通常首次剂量50mg/kg~60mg/kg,维持量10mg/kg~20mg/kg。 全血输注存在很多弊端,目前主张不用或少用全血,输全血的适应证越来越少,其主要用于:
7. 大失血时药物辅助治疗 严重渗血时,若常规治疗手段均失败,可考虑使用重组活化凝血因子Ⅶ,它还可用于治疗合并低温或酸中毒的凝血障碍,其使用剂量为90μg/kg~120μg/kg,可反复使用; (5)氨甲环酸: 应用于纤溶亢进时,可明显减少患者输血量,推荐剂量为20mg/kg~25mg/kg,可反复使用或1mg/(kg·h)~2mg/(kg·h)静脉泵注维持; (6)Ca2+: 维持正常的钙离子水平(≥0.9 mmol/L)有助于维持凝血功能正常; (7)去氨加压素: 预防性应用可使甲型血友病和血管性血友病患者术中出血减少,但重复使用可使疗效降低。
自体输血可以避免输注异体血时的潜在输血反应、血源传播性疾病和免疫抑制,对一时无法获得同型血的患者也是唯一血源。 1.贮存式自体输血 术前一定时间采集患者自身的血液进行保存,在手术期间使用。 (1)适应证
(2)禁忌证
(3)注意事项
2.急性等容性血液稀释 急性等容性血液稀释一般在麻醉后、手术主要出血步骤开始前,抽取患者一定量的自体血在室温下保存备用,同时输入胶体液或一定比例晶体液补充血容量,以减少手术出血时血液的有形成份丢失。待主要出血操作完成后或根据术中失血及患者情况,将自体血回输给患者。 (1)适应证 患者身体一般情况良好,血红蛋白≥110g/L(血细胞比容≥0.33),估计术中失血量大时,可以考虑进行急性等容性血液稀释。年龄并非该技术的禁忌;当手术需要降低血液粘稠度,改善微循环时也可采用该技术。 (2)禁忌证
(3)注意事项
3. 回收式自体输血 血液回收是指使用血液回收装置,将患者体腔积血、手术失血及术后引流血液进行回收、抗凝、洗涤、滤过等处理,然后回输给患者。 血液回收必须采用合格的设备,回收处理的血液必须达到一定的质量标准。体外循环后的机器余血应尽可能回输给患者。 回收式自体输血推荐用于预计血量较大的手术,如体外循环、骨科手术、颅脑外科及大血管手术、胸腹腔闭合出血的手术。也可谨慎用于特殊的产科患者(胎盘疾病、预计出血量大),应用时需采用单独吸引管道回收血液,并于回输时使用白细胞滤器或微聚体滤器。 当Rh阴性血型产妇使用自体血回输后,建议检测母体血液中胎儿红细胞含量。 回收血液的禁忌证:
输入异体血可能抑制受血者的免疫功能,可能影响疾病的转归。应严格遵循输血适应证,避免不必要的输血。 如发生输血不良反应,治疗措施包括:
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