Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
Anesth Analg. 2010 Feb 1;110(2):354-64. doi: 10.1213/ANE.0b013e3181c84ba5. Epub 2009 Dec 10.
A multidisciplinary panel consisting of experts chosen by the 2 chairs of the group representing experts in anesthesiology, blood banking, hematology, critical care medicine, and various surgical disciplines (trauma, cardiac, pediatric, neurologic, obstetrics, and vascular) convened in January 2008 to discuss hemostasis and management of the bleeding patient across different clinical settings, with a focus on perioperative considerations. Although there are many ways to define hemostasis, one clinical definition would be control of bleeding without the occurrence of pathologic thrombotic events (i.e., when balance among procoagulant, anticoagulant, fibrinolytic, and antifibrinolytic activities is achieved). There are common hemostatic challenges that include lack of scientific evidence and standardized guidelines for the use of therapeutic drugs, need for reliable and rapid laboratory tools for measuring hemostasis, and individual variability. Clinically meaningful and accurate real-time laboratory data reflecting a patient's hemostatic status are needed to guide treatment decisions. Current available routine laboratory tests of hemostasis (e.g., platelet count, prothrombin time/international normalized ratio, and activated partial thromboplastin time) do not reflect the complexity of in vivo hemostasis and can mislead the clinician. Although point-of-care coagulation monitoring tests including measures of thromboelastography/elastometry provide insight into overall hemostatic status, they are time-consuming to perform, complex to interpret, and require trained personnel. There is a particular need to develop laboratory tests that can measure the effects of anticoagulant and antiplatelet agents for individual patients, predict bleeding complications, and guide therapy when and if treatment with blood products or pharmacologic drugs is required. Formation of an organization comprised of specialists who treat bleeding patients will foster multidisciplinary collaborations and promote discussions of the current state of hemostasis treatment and future priorities for hemostasis research. Controlled trials with clinically meaningful end points and suitable study populations, as well as observational studies, investigator-initiated studies, and large registry and database studies are essential to answer questions in hemostasis. Because of the complexities of maintaining hemostatic balance, advances in hemostasis research and continuing communication across specialties are required to improve patient care and outcomes.
一个由 2 位主席挑选的多学科专家小组组成，代表麻醉学、血液学、重症监护医学和各种外科专业（创伤、心脏、儿科、神经科、产科和血管）的专家，于 2008 年 1 月召开会议，讨论不同临床环境下的止血和出血患者的管理，重点是围手术期的考虑因素。尽管有许多方法可以定义止血，但一种临床定义是控制出血而不发生病理性血栓形成事件（即当促凝、抗凝、纤溶和抗纤溶活性之间达到平衡时）。常见的止血挑战包括缺乏治疗药物使用的科学证据和标准化指南、需要可靠和快速的止血实验室工具以及个体差异。需要有临床意义和准确的实时实验室数据来反映患者的止血状态，以指导治疗决策。目前可用的常规止血实验室检测（例如血小板计数、凝血酶原时间/国际标准化比值和激活部分凝血活酶时间）不能反映体内止血的复杂性，可能会误导临床医生。尽管即时凝血监测测试（包括血栓弹力图/弹性测量）提供了对整体止血状态的深入了解，但它们执行起来耗时，解释复杂，需要经过培训的人员。特别需要开发可以测量个体患者抗凝和抗血小板药物效果的实验室检测，预测出血并发症，并在需要时指导治疗，例如是否需要使用血液制品或药物治疗。成立一个由治疗出血患者的专家组成的组织将促进多学科合作，并促进对当前止血治疗状况和未来止血研究重点的讨论。具有临床意义的终点和合适的研究人群的对照试验，以及观察性研究、研究者发起的研究和大型登记和数据库研究，对于回答止血问题至关重要。由于维持止血平衡的复杂性，需要在止血研究方面取得进展，并在各专业之间保持持续沟通，以改善患者的护理和结果。
