患者血液管理方案改善骨科手术中的血液使用和临床结局。

Patient Blood Management Program Improves Blood Use and Clinical Outcomes in Orthopedic Surgery.

机构信息

From the Department of Anesthesiology/Critical Care Medicine (V.M.D., S.M.F.) Department of Orthopaedic Surgery (R.M.A., H.S.K., R.S.S.) Department of Pathology (Transfusion Medicine; E.A.G., R.G., P.M.N.) The Johns Hopkins School of Medicine (P.B.G.), Baltimore, Maryland Simmons Cancer Institute at Southern Illinois University, Springfield, Illinois (R.G.) Armstrong Institute for Patient Safety and Quality (K.H.K.L., S.M.F.) The Johns Hopkins Health System Blood Management Program (S.M.F.), The Johns Hopkins Medical Institutions, Baltimore, Maryland Hofstra University School of Medicine, Hempstead, New York (W.W.Y.).

出版信息

Anesthesiology. 2018 Dec;129(6):1082-1091. doi: 10.1097/ALN.0000000000002397.

DOI:10.1097/ALN.0000000000002397

PMID:30124488

Abstract

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Although randomized trials show that patients do well when given less blood, there remains a persistent impression that orthopedic surgery patients require a higher hemoglobin transfusion threshold than other patient populations (8 g/dl vs. 7 g/dl). The authors tested the hypothesis in orthopedic patients that implementation of a patient blood management program encouraging a hemoglobin threshold less than 7 g/dl results in decreased blood use with no change in clinical outcomes.

METHODS

After launching a multifaceted patient blood management program, the authors retrospectively evaluated all adult orthopedic patients, comparing transfusion practices and clinical outcomes in the pre- and post-blood management cohorts. Risk adjustment accounted for age, sex, surgical procedure, and case mix index.

RESULTS

After patient blood management implementation, the mean hemoglobin threshold decreased from 7.8 ± 1.0 g/dl to 6.8 ± 1.0 g/dl (P < 0.0001). Erythrocyte use decreased by 32.5% (from 338 to 228 erythrocyte units per 1,000 patients; P = 0.0007). Clinical outcomes improved, with decreased morbidity (from 1.3% to 0.54%; P = 0.01), composite morbidity or mortality (from 1.5% to 0.75%; P = 0.035), and 30-day readmissions (from 9.0% to 5.8%; P = 0.0002). Improved outcomes were primarily recognized in patients 65 yr of age and older. After risk adjustment, patient blood management was independently associated with decreased composite morbidity or mortality (odds ratio, 0.44; 95% CI, 0.22 to 0.86; P = 0.016).

CONCLUSIONS

In a retrospective study, patient blood management was associated with reduced blood use with similar or improved clinical outcomes in orthopedic surgery. A hemoglobin threshold of 7 g/dl appears to be safe for many orthopedic patients.

摘要

已知信息

该研究主题的已知信息：本文的新信息：背景：尽管随机试验表明，当患者接受较少的血液时，他们的情况会很好，但仍然存在一种持久的印象，即骨科手术患者需要比其他患者群体更高的血红蛋白输血阈值（8 g/dl 与 7 g/dl）。作者在骨科患者中测试了这一假设，即实施鼓励血红蛋白阈值低于 7 g/dl 的患者血液管理计划会导致血液使用减少，而临床结果没有变化。方法：推出多方面的患者血液管理计划后，作者回顾性评估了所有成年骨科患者，比较了血液管理前后的输血实践和临床结果。风险调整考虑了年龄、性别、手术程序和病例组合指数。结果：实施患者血液管理后，平均血红蛋白阈值从 7.8 ± 1.0 g/dl 降至 6.8 ± 1.0 g/dl（P < 0.0001）。红细胞用量减少了 32.5%（从每 1000 名患者 338 个红细胞单位降至 228 个；P = 0.0007）。临床结果得到改善，发病率降低（从 1.3%降至 0.54%；P = 0.01），复合发病率或死亡率（从 1.5%降至 0.75%；P = 0.035），30 天再入院率（从 9.0%降至 5.8%；P = 0.0002）。65 岁及以上患者的预后改善更为显著。风险调整后，患者血液管理与复合发病率或死亡率降低独立相关（比值比，0.44；95%CI，0.22 至 0.86；P = 0.016）。结论：在回顾性研究中，患者血液管理与减少血液使用相关，同时在骨科手术中具有相似或改善的临床结果。血红蛋白阈值为 7 g/dl 似乎对许多骨科患者是安全的。