Kozek-Langenecker Sibylle A
Department of Anesthesia and Intensive Care, Evangelical Hospital Vienna, Hans-Sachs-Gasse, Vienna, Austria.
Curr Opin Crit Care. 2014 Aug;20(4):460-6. doi: 10.1097/MCC.0000000000000109.
Bleeding can be minimal, severe, life-threatening, or organ-threatening. Depending on the compensatory capacity of the patient, most bleeding events going beyond 20% blood volume may represent an emergency as well as a risk factor for anemia, transfusion, coagulopathy, and tissue hypoperfusion. All these factors are independent predictors for survival in postoperative critical care and are drivers for resource use and costs.
A systematic literature search behind the guidelines from the European Society of Anesthesiology on the management of severe perioperative bleeding gives an up-to-date evidence-based summary of strategies intended to correct hemostasis, control bleeding, and increase patient safety. The current review discusses information, recommendations, and suggestions in the European Society of Anesthesiology guidelines, which appear applicable to the bleeding patient after the end of surgery.
Individualized coagulation management guided by viscoelastic tests and restrictive transfusion behavior are encouraged in clinical practice of critical care. Potential fields of research are multifold, for example, thromboembolic adverse effects of hemostatic interventions in the isochronic postoperative acute-phase response, transfusion restrictions by increasing postoperative tolerance to anemia and erythropoiesis, and implementation of guidelines and institutional algorithms.
出血情况可轻可重，轻者出血量微少，重者则会危及生命或器官功能。根据患者的代偿能力，大多数出血量超过血容量20%的出血事件可能构成紧急情况，同时也是贫血、输血、凝血功能障碍及组织灌注不足的危险因素。所有这些因素都是术后重症监护患者生存的独立预测因素，也是资源使用和成本的驱动因素。
欧洲麻醉学会关于严重围手术期出血管理的指南背后进行的系统文献检索，对旨在纠正止血、控制出血及提高患者安全性的策略给出了最新的循证总结。本综述讨论了欧洲麻醉学会指南中的信息、建议和意见，这些内容似乎适用于手术结束后的出血患者。
在重症监护的临床实践中，鼓励采用基于粘弹性试验的个体化凝血管理及限制性输血策略。潜在的研究领域有很多，例如，止血干预措施在等时术后急性期反应中的血栓栓塞不良反应、通过提高术后对贫血的耐受性及促红细胞生成来限制输血，以及指南和机构算法的实施。
