Likosky Donald S, Dickinson Timothy A, Paugh Theron A
Section of Health Services Research and Quality, Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
Specialty Care, Nashville, Tennessee for the Michigan Society of Thoracic and Cardiovascular Surgeons and the Perfusion Measures and Outcomes (PERForm) Registry.
J Extra Corpor Technol. 2016 Sep;48(3):99-104.
Cardiac surgery accounts for between 15% and 20% of all blood product utilization in the United States. A body of literature suggests that patients who are exposed to even small quantities of blood have an increased risk of morbidity and mortality, even after adjusting for pre-operative risk. Despite this body of literature supporting a restrictive blood management strategy, wide variability in transfusion rates exist across institutions. Recent blood management guidelines have shed light on a number of potentially promising blood management strategies, including acute normovolemic hemodilution (ANH) and retrograde autologous priming (RAP). We evaluated the literature concerning ANH and RAP, and the use of both techniques among centers participating in the Perfusion Measures and outcomes (PERForm) registry. We leveraged data concerning ANH and RAP among 10,203 patients undergoing isolated coronary artery bypass grafting (CABG) procedures from 2010 to 2014 at 27 medical centers. Meta-analyses have focused on the topic of ANH, with few studies focusing specifically on cardiac surgery. Two meta-analyses have been conducted to date on RAP, with many reporting higher intra-operative hematocrits and reduced transfusions. The rate of red blood cell transfusions in the setting of CABG surgery is 34.2%, although varied across institutions from 16.8% to 57.6%. Overall use of ANH was 11.6%, although the utilization varied from .0% to 75.7% across institutions. RAP use was 71.4%, although varied from .0% to 99.0% across institutions. A number of blood conservation strategies have been proposed, with varying levels of evidence from meta-analyses. This uncertainty has likely contributed to center-level differences in the utilization of these practices as evidenced by our multi-institutional database. Perfusion databases, including the PERForm registry, serve as a vehicle for perfusionist's to track their practice, and contribute to multidisciplinary team efforts aimed at assessing and improving the value of cardiac surgical care.
在美国，心脏手术占所有血液制品使用量的15%至20%。大量文献表明，即使是接触少量血液的患者，即使在调整术前风险后，发病和死亡风险也会增加。尽管有大量文献支持限制性血液管理策略，但各机构之间的输血率差异很大。最近的血液管理指南揭示了一些潜在有前景的血液管理策略，包括急性等容血液稀释（ANH）和逆行自体预充（RAP）。我们评估了有关ANH和RAP的文献，以及参与灌注措施与结果（PERForm）登记处的中心对这两种技术的使用情况。我们利用了2010年至2014年期间在27个医疗中心接受单纯冠状动脉旁路移植术（CABG）的10203例患者中有关ANH和RAP的数据。荟萃分析主要集中在ANH主题上，专门针对心脏手术的研究很少。迄今为止，已针对RAP进行了两项荟萃分析，许多报告显示术中血细胞比容更高且输血减少。CABG手术中红细胞输血率为34.2%，尽管各机构之间有所不同，从16.8%到57.6%不等。ANH的总体使用率为11.6%，尽管各机构之间的使用率从0.0%到75.7%不等。RAP的使用率为71.4%，尽管各机构之间的使用率从0.0%到99.0%不等。已经提出了一些血液保护策略，荟萃分析的证据水平各不相同。这种不确定性可能导致了这些做法在各中心使用上的差异，我们的多机构数据库证明了这一点。包括PERForm登记处在内的灌注数据库是灌注师跟踪其实践的工具，并有助于多学科团队努力评估和提高心脏手术护理的价值。
