Cholette Jill M, Swartz Michael F, Rubenstein Jeffrey, Henrichs Kelly F, Wang Hongyue, Powers Karen S, Daugherty L Eugene, Alfieris George M, Gensini Francisco, Blumberg Neil
Department of Pediatrics, University of Rochester, Rochester, New York.
Department of Surgery, University of Rochester, Rochester, New York.
Ann Thorac Surg. 2017 Jan;103(1):206-214. doi: 10.1016/j.athoracsur.2016.05.049. Epub 2016 Aug 3.
The optimal hemoglobin for infants after cardiac operation is unknown. Red blood cells (RBCs) are commonly transfused to maintain high hemoglobin concentrations in the absence of a clinical indication. We hypothesized that infants can be managed with a postoperative conservative RBC transfusion strategy, resulting in lower daily hemoglobin concentrations, without evidence of impaired oxygen delivery (ie, lactate, arteriovenous oxygen difference [avOdiff]), or adverse clinical outcomes.
Infants weighing 10 kg or less undergoing biventricular repair or palliative (nonseptated) operation were randomly assigned to either a postoperative conservative or liberal transfusion strategy. Conservative group strategy was RBC transfusion for a hemoglobin less than 7.0 g/dL for biventricular repairs or less than 9.0 g/dL for palliative procedures plus a clinical indication. Liberal group strategy was RBC transfusion for hemoglobin less than 9.5 g/dL for biventricular repairs or less than 12 g/dL for palliative procedures regardless of clinical indication.
After the operation of 162 infants (82 conservative [53 biventricular, 29 palliative], 80 liberal [52 biventricular, 28 palliative]), including 12 Norwood procedures (6 conservative, 6 liberal), daily hemoglobin concentrations were significantly lower within the conservative group than the liberal group by postoperative day 1 and remained lower for more than 10 days. The percentage of patients requiring a RBC transfusion, number of transfusions, and volume of transfusions were all significantly lower within the conservative group. Despite lower hemoglobin concentrations within the conservative group, lactate, avOdiff, and clinical outcomes were similar.
Infants undergoing cardiac operation can be managed with a conservative RBC transfusion strategy. Clinical indications should help guide the decision for RBC transfusion even in this uniquely vulnerable population. Larger multicenter trials are needed to confirm these results, and focus on the highest risk patients would be of great interest.
心脏手术后婴儿的最佳血红蛋白水平尚不清楚。在没有临床指征的情况下，通常会输注红细胞（RBC）以维持高血红蛋白浓度。我们假设婴儿可以采用术后保守的红细胞输注策略进行管理，从而使每日血红蛋白浓度降低，而不会出现氧输送受损（即乳酸、动静脉血氧差[avOdiff]）的证据或不良临床结局。
体重10kg或以下接受双心室修复或姑息性（非分隔）手术的婴儿被随机分配到术后保守或宽松输血策略组。保守组策略是，对于双心室修复，血红蛋白低于7.0g/dL时输注红细胞；对于姑息性手术，血红蛋白低于9.0g/dL时输注红细胞，外加临床指征。宽松组策略是，对于双心室修复，血红蛋白低于9.5g/dL时输注红细胞；对于姑息性手术，血红蛋白低于12g/dL时输注红细胞，无论有无临床指征。
162例婴儿（82例保守组[53例双心室修复，29例姑息性手术]，80例宽松组[52例双心室修复，28例姑息性手术]）手术后，包括12例诺伍德手术（6例保守组，6例宽松组），保守组术后第1天的每日血红蛋白浓度显著低于宽松组，并在10多天内一直较低。保守组中需要输注红细胞的患者百分比、输注次数和输血量均显著较低。尽管保守组血红蛋白浓度较低，但乳酸、avOdiff和临床结局相似。
接受心脏手术的婴儿可以采用保守的红细胞输注策略进行管理。即使在这个特别脆弱的人群中，临床指征也应有助于指导红细胞输注的决策。需要更大规模的多中心试验来证实这些结果，并关注最高风险患者将非常有意义。
Zotero 插件