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Effect of Tissue Perfusion Oriented Red Blood Cell Transfusion Strategy on Outcomes of Critically Ill Patients
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摘要:
目的 比较依据美国东部创伤外科学会/美国重症医学院/美国重症医学联合会(Eastern Association for Surgery of Trauma/American College of Critical Care Medicine/Society of Critical Care Medicine, EAST/ACCM/SCCM)成人创伤与重症患者输血指南(2009年)的红细胞(red blood cell, RBC)输注策略与组织灌注导向的RBC输注策略对重症患者预后影响的差异。 方法 北京协和医院重症医学科在2013年采用依据EAST/ACCM/SCCM成人创伤与重症患者输血指南(2009年)的RBC输注策略指导临床输血, 2014年采用组织灌注导向的RBC输注策略指导临床输血。比较两年所有重症监护病房(intensive care unit, ICU)患者和急性生理学及慢性健康状况评分Ⅱ(Acute Physiology and Chronic Health Evaluation Ⅱ, APACHE Ⅱ)≥ 15分患者的住院死亡率、ICU停留时间、新发的器官功能损伤发病率、输RBC前平均血红蛋白(hemoglobin, Hb)水平、入ICU血乳酸水平(Lac入)、输RBC前血乳酸水平(Lac输RBC前)、人均RBC输注量, 以及输血相关并发症发生率。 结果 2014年ICU收治患者2638例, 2013年2110例。2014年患者平均入ICU APACHE Ⅱ评分及APACHE Ⅱ评分≥ 15分患者占所有患者比例均高于2013年(P < 0.05)。2014年输注RBC患者占所有患者比例显著低于2013年(P < 0.05)。两年间输血前Hb水平、Lac入、Lac入 < 4 mmol/L患者占所有患者比例差异均无统计学意义(P> 0.05)。2014年Lac输RBC前显著高于2013年[(4.16±1.18)mmol/L比(2.78±1.03)mmol/L, P=0.031], 2014年输RBC患者中Lac入 < 4 mmol/L患者占所有患者比例显著低于2013年(20.5%比33.4%, P=0.018), 人均RBC输注量2014年比2013年显著下降[(1.02±0.51)U比(1.55±0.70)U, P=0.037]。全部ICU患者两年间住院死亡率差异无统计学意义(2.77%比2.39%, P=0.749), 但平均ICU停留时间2014年明显较短[(5.31±1.98)d比(6.84±2.36)d, P=0.025];新发的急性肾损伤、急性肝损伤、急性心肌损伤及急性肺损伤的发病率两年间差异均无统计学意义(P>0.05)。而在APACHE Ⅱ ≥ 15分患者中, 2014年住院死亡率比2013年显著降低(7.00%比12.01%, P=0.018), 平均ICU停留时间显著短于2013年[(7.16±3.53)d比(12.44±5.27)d, P < 0.001], 新发的急性肾损伤、急性心肌损伤及急性肺损伤的发病率也显著低于2013年(P < 0.05)。两年均未发生输血相关感染及输血相关性溶血的不良事件。总ICU患者及APACHE Ⅱ ≥ 15分患者的非溶血性发热性输血反应及输血相关肺损伤发病率两年间差异无统计学意义(P>0.05)。 结论 组织灌注导向的RBC输注策略与EAST/ACCM/SCCM指南指导下的RBC输注策略相比, 能够有效降低ICU患者RBC输注量, 缩短ICU停留时间, 特别是对APACHE Ⅱ ≥ 15分的重症ICU患者, 还能有效降低其住院死亡率, 降低新发急性肾损伤、急性心肌损伤及急性肺损伤的发病率, 而不增加输血相关并发症发生率。 Abstract:Objective To compare the effects of Eastern Association for Surgery of Trauma/AmericanCollege of Critical Care Medicine/Society of Critical Care Medicine (EAST/ACCM/SCCM) red blood cell transfusion in adult trauma and critical care guidelines (2009) guided red blood cell (RBC) transfusion strategy and tissue perfusion oriented RBC transfusion strategy in critically ill patients. Methods In 2013, RBC transfusion in Department of Critical Care Medicine of Peking Union Medical College Hospital followed the EAST/ACCM/SCCM guidelines recommendation in critically ill patients, and in 2014 tissue perfusion oriented RBC transfusion strategy was adopted. The in-hospital mortality, length of Intensive Care Unit (ICU) stay, incidence of new organ injury, mean pre-transfusion hemoglobin (Hb) level, blood lactate acid level upon admission (Lac admitted), pre-transfusion blood lactate acid level (Lac pre-transfusion), mean RBC transfusion volume, and incidence of transfusion-related complications in all ICU patients and patients with Acute Physiology and Chronic Health Evaluation Ⅱ(APACHE Ⅱ) ≥ 15 were compared between the year 2013 and the year 2014. Results In 2013 and 2014, 2110 and 2638 patients were admitted to ICU, respectively. The mean APACHE Ⅱ score upon admission and the proportion of patients with APACHE Ⅱ ≥ 15 were both higher in 2014 than in 2013(P < 0.05). The proportion of patients treated with RBC transfusion was significantly lower in 2014 than in 2013(P < 0.05). The mean pre-transfusion Hb level, Lac admitted, and the proportion of patients with Lac admitted < 4 mmol/L showed no significant difference between the two years (P>0.05). Lac pre-transfusion in 2014 was significantly higher than that in 2013[(4.16±1.18)mmol/L vs. (2.78±1.03)mmol/L, P=0.031]. In the patients treated with RBC transfusion, the proportion of patients with Lac admitted < 4 mmol/L was significantly lower in 2014 than in 2013 (20.5% vs. 33.4%, P=0.018). The mean RBC transfusion volume was significant lower in 2014 than in 2013[(1.02±0.51)U vs. (1.55±0.70)U, P=0.037]. The in-hospital mortality was not significantly different between the two years in all ICU patients (2.77% vs. 2.39%, P=0.749), but the mean length of ICU stay was significantly shorter in 2014 than in 2013[(5.31±1.98)d vs. (6.84±2.36)d, P=0.025]. The incidences of new onset acute kidney injury, acute liver injury, acute myocardial injury, and acute lung injury showed no significant difference between the two years (P>0.05). In patients with APACHE Ⅱ ≥ 15, the in-hospital mortality was significant lower (7.00% vs. 12.01%, P=0.018) and the length of ICU stay significantly shorter in 2014 than in 2013[(7.16±3.53)d vs. (12.44±5.27)d, P < 0.001]; the incidences of new onset acute kidney injury, acute myocardial injury, and acute lung injury were significantly lower in 2014 (P < 0.05). No transfusion-related infection or hemolysis occurred in the two years. The incidences of non-hemolytic febrile transfusion reaction and transfusion-related lung injury in all the ICU patients and patients with APACHE Ⅱ ≥ 15 were not significantly different between the two years (P>0.05). Conclusions Compared with EAST/ACCM/SCCM guideline based RBC transfusion strategy, tissue perfusion oriented RBC transfusion strategy in critically ill patients can reduce RBC transfusion volume and shorten length of ICU stay. Especially for ICU patient with APACHE Ⅱ ≥ 15, it can also reduce in-hospital mortality and incidences of new onset acute kidney injury, acute myocardial injury, and acute lung injury, without increasing the incidence of transfusion-related complications. -
Key words:
- tissue perfusion /
- lactate acid /
- red blood cell /
- acute kidney injury /
- acute myocardial injury /
- acute lung injury
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图 1 美国东部创伤外科学会/美国重症医学院/美国重症医学联合会输血指南流程[5]
Hb：血红蛋白；RBC：红细胞；1：Hb＜70 g/L；2：无症状患者输血阈值可低于该水平；3：高危心血管疾病患者输血阈值可高于该水平；4：存在氧输送不足证据
表 1 2013年与2014年1月至10月妇科围术期输血量及输血率比较
年份 性别
(男/女)年龄
(x±s，岁)APACHE Ⅱ
(x±s，分)APACHE Ⅱ≥15分
[例(%)]患者来源[例(%)] 基础疾病[例(%)] 围术期 内科 肺部疾病 肾脏疾病 心血管疾病 肝脏疾病 恶性肿瘤 2013年(n=2110) 1084/1026 53.6±17.9 10.4±4.6 483(22.9) 1479(70.1) 631(29.9) 663(31.4) 211(10.0) 1084(51.4) 181(8.6) 694(32.9) 2014年(n=2638) 1467/1171 54.9±14.7 13.8±5.9* 923(35.0)* 1731(65.6) 907(34.4) 609(23.1) 327(12.4) 1440(54.6) 198(7.5) 49(30.6) ICU:重症监护病房; APACHE Ⅱ:急性生理学及慢性健康状况评分Ⅱ; 与2013年比较，* P＜0.05 
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表 2 2013年和2014年ICU患者输血流程比较
年份 全部ICU患者 APACHE Ⅱ≥15分患者 Lac入
(x±s，
mmol/L)Lac入＜4 mmol/L
占全部ICU患者
比例[例(%)]Hb＜
70 g/L
患者
(例)Hb＜70 g/L
患者接受RBC
输注比例
[例(%)]Hb阈值
(x±s，g/L)接受RBC
输注患者
[例(%)]Lac输RBC前
(x±s，
mmol/L，)输RBC患者中
Lac入＜4 mmol/L
的比例
[例(%)]人均RBC
输注量
(x±s, U)Lac入
(x±s,
mmol/L)Lac入＜4 mmol/L
占当年APACHE
Ⅱ≥15分患者
比例[例(%)]Hb＜
70 g/L
患者
(例)Hb＜70 g/L
患者接受RBC
输注者
[例(%)]Hb阈值
(x±s,
g/L)接受RBC
输注患者
[例(%)]Lac输RBC前
(x±s,
mmol/L)输RBC患者中
Lac入＜4 mmol/L
的比例
[例(%)]人均RBC
输注量
(x±s, U)2013年 1.76±0.45 1599(75.8) 535 535(100) 78.89±12.91 622(29.5) 2.78±1.03 208(33.4) 1.55±0.70 2.78±0.95 126(26.1) 351 351(100) 72.25±15.48 386(79.9) 3.13±0.87 107(27.7) 3.62±1.02 2014年 1.83±0.39 1941(73.6) 598 503(84.1)* 78.37±16.86 546(20.7)* 4.16±1.18* 112(20.5)* 1.02±0.51* 3.03±1.08 229(24.8) 516 461(89.5)* 73.15±14.10 467(50.6)* 4.26±1.14* 86(18.4)* 1.96±0.73* ICU、APACHE Ⅱ：同表 1；Lac入：入ICU血乳酸水平；Hb阈值：输血前平均血红蛋白水平；Lac输RBC前：输血前血乳酸水平；输RBC患者中Lac入＜4 mmol/L的比例：输RBC患者中Lac入＜4 mmol/L的患者数/输RBC患者总数；与2013年比较，* P＜0.05
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表 3 2013年和2014年ICU患者输血原因比较[例(%)]
年份 全部ICU患者 APACHE Ⅱ≥15分患者 急性失血 纠正贫血 纠正组织灌注 急性冠脉综合征 其他原因 急性失血 纠正贫血 纠正组织灌注 急性冠脉综合征 其他原因 2013年(n=622) 73(11.7) 283(45.5) 118(18.9) 105(16.9) 43(6.9) 52(13.5) 180(46.6) 83(21.5) 65(16.8) 6(1.6) 2014年(n=546) 26(4.8)* 57(10.4)* 358(65.6)* 89(16.3) 16(2.9) 26 (5.5)* 57(12.2)* 308(66.0)* 67(15.2) 9(1.9) ICU、APACHE Ⅱ：同表 1；†纠正贫血指输血目的为单纯纠正贫血，而不存在急性失血、组织灌注不足、冠心病或循环容量不足等情况；与2013年比较，*P＜0.05
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表 4 2013年和2014年非输血治疗指南实现率比较[例(%)]
年份 血流动力学早期目标指导治疗 激素应用 抗生素应用策略 强化胰岛素治疗 保护性机械通气策略 深静脉血栓的预防 应激性溃疡的预防 镇痛镇静治疗 营养支持治疗 2013年(n=2110) 1483(70.3) 211(10.0) 1937(91.8) 1589(75.3) 1283(60.8) 1390(65.9) 1063(50.4) 1975(93.6) 1593(75.5) 2014年(n=2638) 1915(72.6) 253(9.6) 2456(93.1) 2058(78.0) 1549(58.7) 1807(68.5) 1417(53.7) 2485(94.2) 2034(77.1)
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表 5 2013年和2014年ICU患者新发器官损伤发病率比较[例(%)]
年份 全部ICU患者 APACHE Ⅱ≥15分患者 急性肾损伤 急性肝损伤 急性心肌损伤 急性肺损伤 急性肾损伤 急性肝损伤 急性心肌损伤 急性肺损伤 2013年 456(21.6) 289(13.7) 390(18.5) 544(25.8) 248(51.3) 185(38.4) 293(60.7) 280(58.0) 2014年 522(19.8) 377(14.3) 446(16.9) 588(22.3) 296(32.1)* 322(34.9) 383(41.5)* 312(33.8) ICU、APACHE Ⅱ：同表 1；与2013年比较，* P＜0.05
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