Clinical Characteristics of Patients with Hemoglobin Level before Red Blood Cell Transfusion Higher than Recommended Threshold in Non-surgical Departments of Peking Union Medical College Hospital
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摘要:
目的 探讨北京协和医院非手术科室红细胞输注前血红蛋白高于输血指南推荐阈值患者的临床特点。 方法 对2013年1月至12月在北京协和医院住院期间行红细胞输注的患者随机抽样1000例, 筛选出红细胞输注前血红蛋白值≥ 70 g/L的非手术科室患者的资料, 对其红细胞输注前血红蛋白、在非手术科室红细胞输注患者中所占比例、输血前与贫血相关的症状及体征等进行描述性分析。 结果 住院期间接受红细胞输注的非手术科室患者270例, 红细胞输注前平均血红蛋白(63.7±11.5)g/L, 其中红细胞输注前血红蛋白≥ 70 g/L者74例(27.4%), 包括血红蛋白≥ 70 g/L且 < 80 g/L者60例(22.2%), 血红蛋白≥ 80 g/L且 < 90 g/L者10例(3.7%)和血红蛋白≥ 90 g/L者4例(1.5%)。74例患者中, 59例(79.7%)在病程记录中描述了与输血相关的症状、体征及红细胞输注临床决策, 未描述的15例(20.3%)均为原发病较重、合并症多、可能伴有多系统受累和临床状况不稳定、对血红蛋白下降耐受较差的患者。 结论 北京协和医院非手术科室红细胞输注前血红蛋白阈值基本符合国际输血指南和我国《临床输血技术规范》所推荐范围。结合红细胞输注前血红蛋白高于指南推荐阈值患者的具体病情, 其输血具有临床合理性, 但在今后的临床记录中应对临床输血决策进一步给予详细的描述与分析。 -
关键词:
- 红细胞输注前血红蛋白 /
- 血红蛋白阈值 /
- 合理用血 /
- 非手术科室
Abstract:Objective To investigate the clinical characteristics of patients with hemoglobin level higher than the recommended threshold by guidelines before receiving red blood cell (RBC) transfusion in non-surgical departments of Peking Union Medical College Hospital (PUMCH). Methods One thousand patients were randomly selected from hospitalized patients who received RBC transfusion at PUMCH between January and December in 2013. Among them, those in non-surgical departments and with hemoglobin ≥ 70 g/L before transfusion were identified, and their hemoglobin level before RBC transfusion, proportion in non-surgical patients receiving RBC transfusion, symptoms and signs related to anemia before transfusion were described. Results Of the 1000 patients, 270 were from non-surgical departments, and their average hemoglobin before RBC transfusion was (63.7±11.5)g/L. Seventy-four of the 270 (27.4%) patients had hemoglobin ≥ 70 g/L before RBC transfusion, including 60 (22.2%) patients with homoglobin ≥ 70 g/L and < 80 g/L, 10 (3.7%) patients with homoglobin ≥ 80 g/L and < 90 g/L, and 4 (1.5%) patients with hemoglobin ≥ 90 g/L. Among the 74 patients, symptoms and signs related to anemia and decision-making of the transfusion were identified in 59(79.7%) patients' medical records, the other 15(20.3%) patients with missing data were those with more severe conditions, multiple co-morbidities, multi-organ involvement, unstable conditions, or poor tolerance to decreasing hemoglobin level. Conclusions The hemoglobin threshold for RBC transfusion in non-surgical departments of PUMCH was consistent with the recommendations of both international and Chinese guidelines. Given specific conditions, RBC transfusion in those patients with hemoglobin level higher than the recommended threshold is clinically appropriate, but the decision-making process regrading RBC transfusion should be recorded in detail. 近10年来,北京协和医院临床用血的综合指标一直处于全国前列,究其原因,很大程度上取决于医院的文化和科学的管理,其中连续7年的“北京协和医院合理用血周”就是一个成功的举措。临床合理用血是一个复杂的系统工程,需要多学科的团队协作,一时领先容易,保持领先不易。统计数据显示,2015年1月至10月全院输注红细胞总量较去年同期上升6.26%,而累计输注红细胞≥20 U的患者输注量超过红细胞总量的40%,其中围术期患者非计划用血包括术中输注红细胞≥20 U的现象值得关注。红细胞用量的反弹引发临床科室高度关注和广泛讨论,并成为2015年北京协和医院第七届“合理用血周”活动的讨论热点。为此,在2015年北京协和医院第七届“合理用血周”活动中,外科学系、妇产科学系、内科学系和平台科室(包括麻醉科、输血科、急诊科和重症医学科等)分别组织3场别开生面的工作研讨会,对累计输注红细胞≥20 U的病例进行了回顾性总结,对红细胞输注量的影响因素如患者情况、术前准备及评估、术中情况、输血指征的把握及预后等进行了系统分析。研究结果显示,术前评估及术前多科全面会诊对于输血决策及病情评估至关重要;加强科室间协作,准确把握手术时机,正确把握输血指征,理顺临床科学用血流程,加大监管力度均有助于降低输血量。本刊将相关科室撰写的部分研究成果以专栏形式进行发表。通过分享,强化多学科换位思考,以期达到持续推进合理用血、确保患者安全的目标。临床科学、合理用血是一个漫长的旅程,没有终点,唯有始终关注、发现问题、持续改进(PDCA),协和的临床用血文化方可长盛不衰。红细胞输注在内科等非手术科室的应用是现代输血疗法的重要组成部分,随着成分输血的普及,血制品使用的安全性越来越受到重视。北京协和医院普通内科长期关注临床合理用血问题,2011年正式受邀参加由美国国立卫生研究院(National Institute of Health,NIH)心-肺-血液研究所与约翰·霍普金斯大学输血科领导的大型输血研究项目逆转录病毒在献血者中的流行病学调查(Retrovirus Epidemiology Donor,RED)第三阶段的研究。为制定更为合理的输血策略,REDⅢ在前期研究的基础上增加了对受血者临床实际状况的研究,纳入包括北京协和医院在内的5所中国大型医院参与临床用血调查。项目临床用血研究部分的领导者是Rutgers Robert Wood Johnson医学院普通内科的Jeffrey L Carson教授,他长期致力于限制性输血策略(即对于病情相对平稳的患者采用血红蛋白<70 g/L、围术期患者<80 g/L为红细胞输注阈值)的安全性研究[1-5]。我国2000年发布的《临床输血技术规范》和目前国际上常用的输血指南也推荐对非急性出血的非手术患者在血红蛋白<70 g/L时行红细胞输注[6-9]。本研究对2013年本院住院期间行红细胞输注患者进行抽样调查,分析非手术科室住院患者红细胞输注前血红蛋白≥70 g/L患者的临床用血情况。 -
表 1 红细胞输注前血红蛋白≥90g/L患者的临床情况
病例 性别 年龄(岁) 血红蛋白(g/L) 基础疾病 临床问题 症状 1 女 58 92 宫颈癌(放化疗中) 急性冠脉综合征,支架置入术后,伴
高血压、高脂血症疲乏、胸痛 2 男 76 94 肺癌,多发转移 椎体转移,脊髓受压,尿潴留,住院
期间行椎旁肿物切除术未描述 3 女 50 107 皮肌炎,肺间质病变、
心肌受累肺部感染、呼吸衰竭、感染性休克 虚弱、心动过速、活动后
气促4 女 51 117 系统性硬化、肺动脉
高压急性冠脉综合征,支架置入术后 穿刺处血肿、胸痛、血压下
降(最低51/36 mm Hg)表 2 59例红细胞输注前血红蛋白≥70 g/L患者病程记录中对红细胞输注相关症状与体征的描述
输血相关症状
与体征例数 占记录贫血相关症状
总例数比例(%)虚弱 33 55.9 心动过速 29 49.2 易疲乏 20 33.9 气促 13 22.0 低血压 10 16.9 出血 8 13.6 眩晕 4 6.8 胸痛 2 3.4 心律失常 2 3.4 血肿 2 3.4 心力衰竭 1 1.7 心悸 1 1.7 表 3 15例病程记录中未描述与红细胞输注相关症状与体征患者的临床情况
原发病 例数 临床情况 肺恶性肿瘤 8 4例多发转移,1例复发,1例为二次肿瘤,
1例合并类风湿所致肺间质纤维化系统性红斑狼疮 2 合并肾脏等多系统受累,1例合并冠心病,
1例肺部感染急性粒细胞白血病 2 均为初治,其中1例为56岁男性,期间出
现肺部感染,基础疾病有高血压、糖尿病再生障碍性贫血 1 78岁男性,合并冠心病,冠脉搭桥术后 化脓性胸膜炎 1 反复发热、寒战,消耗,营养状况不佳 不明原因发热 1 血液系统恶性肿瘤可能性大,一般状况差 -
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