From the Department of Anaesthetics, Royal Free Hospital, London, United Kingdom.
Centre for CardioVascular and Interventional Research (CAVIAR), University College London, London, United Kingdom.
Anesth Analg. 2018 Nov;127(5):1211-1220. doi: 10.1213/ANE.0000000000002549.
Anemia is common in elective surgery and is an independent risk factor for morbidity and mortality. Historical management of anemia has focused on the use of allogeneic blood transfusion but this in itself is not without risk. It too has been independently associated with morbidity and mortality, let alone the costs and relative shortage of this resource. In recognition of this, patient blood management (PBM) shifts the focus from the product to the patient and views the patient's own blood as a resource that should be conserved and managed appropriately as a standard of care. It consists of 3 pillars: the optimization of red blood cell mass; reduction of blood loss and bleeding; and optimization of the patient's physiological tolerance toward anemia. Integration of these 3 pillars in the form of multimodal care bundles and strategies into perioperative pathways should improve care processes and patient outcome. Preoperative anemia is most commonly caused by functional iron deficiency and should be treated with oral iron, intravenous iron, and/or recombinant erythropoietin. An individualized assessment of the thrombotic risk of discontinuing anticoagulant and antiplatelet medication should be balanced against the risk of perioperative bleeding. Neuraxial anesthetic techniques should be considered and minimally invasive surgery undertaken where appropriate. Cell salvage should be used if significant blood loss is anticipated and pharmacological treatments such as tranexamic acid and fibrin sealants have been shown to reduce blood loss. Point of care tests can guide the perioperative management of dynamic coagulopathy. Blood testing sampling should be performed only when indicated and when taken, sample volume and waste should be minimized. Restrictive blood transfusion thresholds and reassessment after single unit transfusion should be incorporated into clinical practice where appropriate. For PBM to become standard practice in routine surgical care, national health care quality change initiatives must set the agenda for change but the patient-centered approach to PBM should be delivered in a way that is also hospital centered. Characterization of the current practice of PBM at each hospital is crucial to facilitate the benchmarking of performance. Barriers to effective implementation such as lack of knowledge should be identified and acted on. Continuous audit of practice with a focus on transfusion rates and patient outcomes can identify areas in need of improvement and provide iterative feedback to motivate and inspire the main stakeholders.
贫血在择期手术中很常见，是发病率和死亡率的独立危险因素。贫血的历史管理重点是使用异体输血，但这本身并非没有风险。它也与发病率和死亡率独立相关，更不用说这种资源的成本和相对短缺了。有鉴于此，患者血液管理（PBM）将重点从产品转移到患者身上，将患者自身的血液视为一种资源，应作为护理标准进行适当的保存和管理。它由三个支柱组成：红细胞质量的优化；减少失血和出血；以及优化患者对贫血的生理耐受能力。将这三个支柱整合为多模式护理包和策略，纳入围手术期途径，应改善护理流程和患者结局。术前贫血最常见的原因是功能性缺铁，应使用口服铁剂、静脉铁剂和/或重组促红细胞生成素治疗。应权衡停止抗凝和抗血小板药物的血栓形成风险与围手术期出血风险，对停止抗凝和抗血小板药物的患者进行个体化评估。应考虑采用神经轴麻醉技术，并在适当情况下进行微创手术。如果预计会大量失血，应使用血液回收，如果已证明氨甲环酸和纤维蛋白密封剂等药物治疗可减少失血，也可使用此类药物。即时检测可指导围手术期动态凝血功能障碍的管理。只有在需要时才进行血液检测采样，应尽量减少采样量和废物量。在适当情况下，应将限制性输血阈值和单单位输血后再次评估纳入临床实践。为了使 PBM 成为常规手术护理的标准实践，国家医疗保健质量改进举措必须为变革设定议程，但应以也以医院为中心的方式提供以患者为中心的 PBM 方法。对每家医院的 PBM 当前实践进行特征描述对于促进绩效基准测试至关重要。应确定并处理实施过程中的障碍，例如知识不足。以输血率和患者结局为重点的持续实践审核可以确定需要改进的领域，并提供迭代反馈，以激励和激发主要利益相关者。
