Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
The Ottawa Hospital, Ottawa, Ontario, Canada.
Ann Surg. 2018 Apr;267(4):766-774. doi: 10.1097/SLA.0000000000002205.
Create practice guidelines for the appropriate use of red blood cell transfusions in hepatectomy.
Hepatectomy is associated with a high prevalence of transfusions. A transfusion can be life-saving, but can be associated with important adverse effects. Given the prevalence, the potential for benefit and harm, and the difficulty in conducting clinical trials, transfusion in hepatectomy is well-suited for a study of appropriateness.
Using the RAND/UCLA appropriateness method, an international, multidisciplinary expert panel in hepatobiliary surgery, anesthesia, transfusion medicine, and critical care rated a series of 468 perioperative scenarios for transfusion appropriateness. Scenarios were rated individually, and again during an inperson group moderated session. Median scores and level of agreement were calculated to classify each scenario as appropriate, inappropriate, or uncertain.
Approximately, 47.4% of scenarios were rated as appropriate for transfusion, 28.2% were inappropriate, and 24.4% were uncertain. The key recommendations for intraoperative transfusion were (i) it is never inappropriate to transfuse for significant bleeding or ST segment changes; (ii) it is never inappropriate to transfuse for an intraoperative hemoglobin ≤75 g/L; and (iii) in the absence of significant bleeding or ST changes, transfusion for hemoglobin of ≥95 g/L is inappropriate, and transfusion for hemoglobin of ≥85 g/L requires strong justification. The key recommendations for postoperative transfusions were: (i) in a stable, asymptomatic patient, an appropriate transfusion trigger is 70 g/L (without coronary artery disease) or 80 g/L (with coronary artery disease) and (ii) it is appropriate to transfuse any patient for a hemoglobin of ≤75 g/L either immediately post-operative, or with a significant decrease from the previous day (>15 g/L).
Based on best available evidence and expert opinion, criteria for appropriate perioperative red blood cell transfusions in hepatectomy were determined.
制定肝切除术红细胞输注合理应用的实践指南。
肝切除术与输血的高发生率相关。输血可能具有救命作用，但也可能与重要的不良反应相关。鉴于输血的高发生率、潜在获益和危害，以及进行临床试验的困难，肝切除术的输血非常适合进行适宜性研究。
使用 RAND/UCLA 适宜性方法，一个国际多学科专家小组，包括肝胆外科、麻醉、输血医学和重症监护，对一系列 468 个围手术期输血适宜性场景进行了评估。对每个场景进行了单独评分，并在现场小组讨论中再次评分。计算中位数评分和一致性水平，以将每个场景归类为适宜、不适宜或不确定。
大约 47.4%的场景被评为输血适宜，28.2%为不适宜，24.4%为不确定。术中输血的关键建议包括：（i）出现明显出血或 ST 段改变时，输血永远不是不合适的；（ii）术中血红蛋白≤75g/L 时，输血永远不是不合适的；（iii）在没有明显出血或 ST 改变的情况下，血红蛋白≥95g/L 时输血不适宜，血红蛋白≥85g/L 时输血需要强有力的理由。术后输血的关键建议包括：（i）在稳定、无症状的患者中，适当的输血触发值为 70g/L（无冠心病）或 80g/L（有冠心病）；（ii）对于血红蛋白≤75g/L 的任何患者，无论是在术后立即，还是与前一天相比有显著下降（>15g/L），输血都是合适的。
根据现有最佳证据和专家意见，确定了肝切除术围手术期红细胞输注的适宜标准。
