Department of Anesthesia, Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
Can J Anaesth. 2013 Feb;60(2):168-75. doi: 10.1007/s12630-012-9861-y. Epub 2013 Jan 25.
Anemia in both acute and chronic conditions is associated with an increased risk of organ injury (brain, heart, kidney) and mortality. Thus, anemia is not "safe". Impairment of tissue oxygen delivery likely contributes as a central mechanism; however, the existing treatments for anemia (i.e., transfusion, erythropoiesis stimulating agents, blood substitutes) have not produced a demonstrable improvement in patient outcomes despite their efficacy to increase blood oxygen content. Indeed, transfusion of red blood cells (RBCs) has been attributed to increase mortality in non-bleeding patients. Thus, the pathophysiology of anemia-induced morbidity and mortality and its treatments are complex and incompletely understood. New knowledge continues to emerge regarding the cellular mechanisms that maintain oxygen homeostasis during anemia. Nevertheless, the application of this knowledge has not yet led to improvements in patient outcomes. As both anemia and transfusion are associated with increased mortality, utilization of multimodal patient blood management strategies may be effective in avoiding both of these predictors of adverse outcomes. We propose to review new strategies to avoid both anemia and transfusion with the goal of improving patient outcomes and safety.
We reviewed several approaches that utilize patient blood management to improve patient outcomes, including 1) characterization of biomarkers of anemia-induced tissue hypoxia to identify appropriate patient-specific treatment thresholds or hemoglobin (Hb) triggers; 2) development of adequately powered clinical trials that will help to define appropriate guidelines for the perioperative treatment of anemia and optimal Hb thresholds for transfusion of RBCs in specific patient populations; and 3) demonstration that an established blood conservation program (ONTraC) can reduce RBC transfusion and its associated adverse outcomes.
Anemia is associated with increased morbidity and mortality. Ongoing initiatives to treat anemia and optimize patient blood management may improve patient outcomes. A broader application of these approaches may improve the overall safety of anesthesia and surgery for patients with anemia.
急性和慢性病症中的贫血与器官损伤（大脑、心脏、肾脏）和死亡率增加相关。因此，贫血并非“安全”。组织氧输送受损可能是一个核心机制；然而，现有的贫血治疗方法（即输血、红细胞生成刺激剂、血液代用品）尽管能增加血液氧含量，但并未显著改善患者预后。事实上，输注红细胞（RBC）已被归因于非出血患者死亡率增加。因此，贫血引起的发病率和死亡率的病理生理学及其治疗方法复杂且尚未完全理解。关于在贫血期间维持氧平衡的细胞机制的新知识不断涌现。然而，这些知识的应用尚未导致患者预后的改善。由于贫血和输血都与死亡率增加相关，因此采用多模式患者血液管理策略可能有助于避免这两个不良结局的预测因素。我们建议审查避免贫血和输血的新策略，以改善患者的预后和安全性。
我们回顾了几种利用患者血液管理来改善患者预后的方法，包括 1）描述贫血诱导的组织缺氧的生物标志物，以确定适当的个体化治疗阈值或血红蛋白（Hb）触发值；2）开展足够规模的临床试验，有助于为围手术期贫血治疗和特定患者人群中 RBC 输血的最佳 Hb 阈值制定适当的指南；以及 3）证明既定的血液保存计划（ONTraC）可以减少 RBC 输血及其相关不良结局。
贫血与发病率和死亡率增加相关。正在进行的治疗贫血和优化患者血液管理的举措可能会改善患者的预后。更广泛地应用这些方法可能会提高贫血患者麻醉和手术的整体安全性。
